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J.  V;  f  \ 

APPLIED  ANATOMY 
AND  ORAL  SURGERY 

FOR  "DENTAL  STUDENTS 


BY 

ROBERT  H.  IVY.  M.D..  D.D.S. 

ASSOCIATE    SURGEON,    COLUMBIA    HOSPITAL,    MILWAUKEE;     FORMER  AS- 
SISTANT   SURGEON,    OUT-PATIENT    DEPARTMENT,   UNIVERSITY    HOSPITAL, 
PHILADELPHIA;    FORMER    INSTRUCTOR    IN    ORAL    SURGERY,     UNIVERSITY 
OF   PENNSYLVANIA 


SECOND    EDITION 
THOROUGHLY  REVISED 


PHILADELPHIA  AND  LONDON 

W.  B.   SAUNDERS   COMPANY 
1917 


Copyright,  1911,  by  W.  B.  Saunders  Company.    Reprinted  September, 

IQ14,  and  January,  1916.    Revised,  reprinted,  and 

recopyrighted  Jtjly,  1917 


Copyright,  1917,  by  W.  B.  Saunders  Company 


PRINTED    IN    AMERICA 

PRESS    OF 

W.     B.     SAUNDERS     COMPANV 

PHILADELPHIA 


PREFACE  TO  THE   SECOND   EDITION 


In  presenting  a  second  edition  the  writer  has  not  at- 
tempted to  enlarge  the  scope  of  the  work,  but  has  confined 
himself  to  making  such  essential  changes  and  slight  ad- 
ditions as  would  bring  the  matter  of  the  first  edition 
up  to  date.  The  criticisms  that  applied  to  the  first  edi- 
tion still  hold  good,  therefore,  to  some  extent  in  regard  to 
the  second,  which  it  is  hoped,  nevertheless,  will  fulfil  the 
object  intended,  as  set  forth  in  the  former  Preface. 

Robert  H.  Ivy. 

Milwaukee,  Wis., 

First  National  Bank  Building 

Jtdy,  191 7. 


PREFACE 

This  book  is  an  attempt  to  collect  in  one  place  and 
in  a  few  words  the  special  anatomy  and  surgery  re- 
quired by  the  dental  student.  It  is  not  intended  to 
replace  larger  works  on  anatomy  and  general  and 
oral  surgery,  but  rather  to  indicate  to  the  student 
the  subjects  that  require  his  particular  attention.  The 
thanks  of  the  writer  are  due  to  Professor  M.  H,  Cryer 
for  valuable  aid  and  suggestions,  and  also  for  the  use 
of  several  illustrations.  My  thanks  are  also  due  Dr. 
William  Francis  Campbell,  of  Brooklyn,  N.  Y.,  for 
kind  permission  to  use  ten  illustrations  from  his 
"  Surgical  Anatomy,"  and  to  Dr.  Daniel  N.  Eisen- 
drath,  of  Chicago,  111.,  for  kind  permission  to  use 
four  illustrations  from  his  "  Surgical  Diagnosis." 

Robert  H.  Ivy, 


11 


CONTENTS 


PART  I.  ANATOMY  OF  THE  FACE,  JAWS,  AND 
ANTERIOR  PORTION  OF  THE  NECK 

Page 

Chapter  I. — Bones 17 

General  Development  of  the  Skull 17 

Bones  of  the  Skull 18 

The  Sphenoid  Bone 18 

The  Ethmoid  Bone 19 

The  Maxilla 20 

The  Mandible 22 

The  Hyoid  Bone... 26 

The  Skull  as  a  Whole:    Anterior  View.      Lateral  View. 

Base 28 

Base  of  the  Skull 29 

The  Orbit 32 

Bony  Roof  of  the  Mouth 33 

The  Nasal  Fossae 34 

The  Maxillary  Sinus 39 

The  Frontal  Sinuses 42 

The  Sphenoid  Sinuses 43 

The  Ethmoid  Air-cells 43 

Chapter  II. — The  Temporomandibular  Articulation 45 

Chapter  III. — Muscles  and  FASciit 47 

Cervical  Fascia 47 

Surgical  Square  and  Triangles  of  the  Neck 48 

Muscles  of  the  Tongue 51 

Muscles  of  the  Pharynx  and  Soft  Palate 53 

Muscles  of  Mastication 55 

Muscles  of  Expression  About  the  Mouth 59 

Muscles  Attached  to  the  Mandible 61 

13 


14  CONTENTS 

Page 

Chapter    IV. — Blood-vessels 5, 

The  Internal  Carotid  Artery 63 

The  External  Carotid  Artery 67 

The  Vertebral  Arteries 68 

Veins  of  the  Head 69 

The  Internal  Jugular  Vein 70 

Chapter  V. — Lymphatics  of  the  Face  and  Neck 72 

Chapter  VI. — The  Cranial  Nerves 74 

Fifth  Nerve 75 

Seventh  Nerve 83 

Chapter  VII. — Glands 88 

Parotid 88 

Submaxillary - 90 

Sublingual 91 

Labial 91 

Buccal 91 

Lingual 91 

Palatal 91 

Chapter  VIII. — The  Tonsils  and  the  Mouth 92 

The  Tonsils 92 

The  Mouth 94 


PART  II.     SURGERY 

GENERAL   CONSIDERATIONS 

Chapter  IX. — Abnormal  Conditions  of  the  Circulation  and 

Composition  of  the  Blood q7 

Hyperemia q7 

Anemia o^ 

Leukocytosis gg 

Leukemia og 

Chapter  X. — Inflammation 99 

Ulceration 104 

Gangrene 105 

Necrosis 105 

Bacteria  Commonly  Associated  with  Surgical  Affections 106 


CONTENTS  1 5 

Page 
Chapter  XI. — Contusions  and  Wounds 109 

Contusions 109 

Wounds 1 10 

Repair  of  Tissue 113 

Chapter  XII.— Surgical  Fever 115 

Septic  Surgical  Fever 115 

Sapremia 116 

Septicemia 117 

Pyemia 118 

Chapter  XIII. — Syncope,  Shock,  Collapse 120 

Hemorrhage 122 

Hemophilia 126 

Chapter  XIV. — Anesthesia 130 

Spinal 130 

Local 130 

General 132 

Ether 133 

Nitrous  Oxid 141 

Ethyl  Chlorid 143 

Tracheotomy 144 

Ligation  of  Common  Carotid  Artery  and  External  Carotid 

Artery ^45 

Chapter  XV. — Preparation  for  Operation 148 

Instruments 149 

Ligatures,  Sutures,  etc 155 

Drainage  Materials 156 

Bandages 157 


SPECIAL  SURGERY 

Chapter  XVI. — Hypertrophy;  Tumors 159 

Neoplasms  or  Tumors 162 

Leukoplakia 172 

Chapter  XVII. — Syphilis  or  Lues 174 

Chapter  XVIIL— Stomatitis 183 


1 6  CONTENTS 

Page 
Chapter  XIX. — Alveolar  Abscess;  Osteomyelitis;  Necrosis; 

Actinomycosis iQi 

Chapter  XX. — Diseases  of  the  Maxillary  Sinus 200 

Chapter  XXI. — Diseases  of  the  Salivary  Glands  and  Their 

Ducts 205 

Ludwig's  Angina 208 

Chapter  XXII. — Diseases  of  the  Tonsils  and  of  the  Lymph- 
atic Glands 211 

Hypertrophy  of  the  Tonsils 211 

Tonsillitis 212 

Adenoids 213 

The  Lymphatic  Glands 213 

Chapter  XXIII. — Injuries   and   Diseases   of   the  Temporo- 
mandibular Articulation 215 

Dislocation 215 

Ankylosis 217 

Chapter  XXIV. — Impacted  Teeth 224 

Indications  for  Extraction  of  Deciduous  Teeth 229 

Chapter  XXV. — Malformations  of  the  Jaws 231 

Cleft-palate 231 

Harelip 237 

Injuries  During  Childbirth 239 

Chapter  XXVI. — Fractures 242 

Fractures  of  the  Mandible 243 

Chapter  XXVII  .—Trifacial  Neuralgia  and  Facial  Paralysis  .  256 

Trifacial  Neuralgia ■ 256 

Facial  Paralysis 264 


INDEX 269 


APPLIED  ANATOMY  AND  ORAL  SUR- 
GERY FOR  DENTAL  STUDENTS 


PART  I 
APPLIED  ANATOMY 


CHAPTER  I 

BONES 
General  Development  of  the  Skull 

The  en-tire  bony  structure  of  the  head  is  developed 
from  the  mesobhistic  layer  of  the  embryo.  The  bones 
forming  the  base  of  the  brain-case  are  first  laid  down 
in  cartilage,  and  those  forming  the  vault  of  the  cranium 
and  the  face  develop  in  membrane,  with  the  exception 
of  the  mandible.  Ossification  commences  from  various 
centers  from  the  sixth  to  the  eighth  week  of  embryonic 
life. 

The  facial  bones  arise  from  the  under  surface  of  the 
base  of  the  brain-case  by  certain  processes  which  push 
downward.  Those  in  front  are  termed  the  frontonasal 
processes,  and  those  laterally,  the  maxillary  and  mandib- 
ular. Failure  of  union  on  the  part  of  these  processes 
brings  about  various  congenital  defects,  such  as  harelip 
and  cleft-palate. 

2  17 


1 8  applied  anatomy 

Bones  of  the  Skull 
The  skull  is  composed  of  22  bones,  of  which  8  belong 
to  the  cranium  and  14  to  the  face,  as  follows: 
Cranium.  Face. 

1  occipital.  2  maxillary. 

2  parietal.  2  malar, 
2  temporal.  2  palate. 

I  frontal.  2  lacrimal. 

I  sphenoid.  2  inferior  turbinated. 

I  ethmoid.  2  nasal. 

I  vomer. 

I  mandible. 

The  following  bones  will  be  described  more  or  less  in 
detail:  sphenoid,  ethmoid,  maxilla,  and  mandible. 

The  Sphenoid  Bone. — The  sphenoid  bone  (Fig.  7) 
is  situated  across  the  base  of  the  skull,  between  the  tem- 
poral bones  laterally,  the  ethmoid  bone  in  front,  and 
the  occipital  bone  behind. 

The  sphenoid  bone  consists  of  a  body  and  six  processes, 
three  on  each  side,  viz. :  the  greater  wing,  the  lesser  wing, 
and  the  pterygoid  process.  The  hody  is  cuboid  in  shape. 
Its  upper  and  lateral  surfaces  are  within  the  brain-case. 
The  posterior  surface  articulates  with  the  occipital  bone. 
The  anterior  surface  forms  part  of  the  roof  of  the  nose,, 
and  presents  the  sphenoid  turbinated  bones  and  the 
openings  of  the  sphenoid  sinuses,  which  are  situated 
within  the  body  of  the  bone.  The  inferior  surface  also 
forms  part  of  the  roof  of  the  nose  and  posterior  wall  of 
the  nasopharynx. 

The  greater  wing  presents  three  surfaces — internal  or 
cerebral,  external  or  temporozygomatic,  and  orbital, 
which  assists  in  forming  the  outer  wall  of  the  orbit 


BOXES 


19 


The  lesser  wing  extends  outwardly  from  the  anterior 
portion  of  the  body,  and  has  two  surfaces.     The  supe- 
rior surface  assists  in  forming  the  anterior  fossa  of  the 
brain-case,  and  the  inferior  sur- 
face  is  part  of  the  roof  of  the 
orbit. 

The  pterygoid  process  projects 
do\\Tiward  from  the  junction  of 
the  greater  wing  with  the  body 
of  the  bone.  It  consists  of  an 
internal  plate  and  an  external 
plate,  separated  by  the  pterygoid 
fossa.  The  lower  extremity  of 
the  internal  pterygoid  plate — 
the  hamular  process — assists  in 
forming  the  bony  framework  of 
the  roof  of  the  mouth. 

The  Ethmoid  Bone.— The  eth- 
moid bone  (Fig.  i)  is  situated 
between  the  orbits  at  the  anterior 
part  of  the  brain-case,  and  forms 
d  portion  of  the  anterior  fossa  of 
the  skull.  It  is  cuboid  in  shape, 
and  consists  of  a  vertical  or  per- 
pendicular plate,  a  horizontal  or 
cribriform  plate,  and  two  lateral 
masses.  The  vertical  or  perpen- 
dicular plate  is  in  the  median 
line,  in  an  anteroposterior  direc- 
tion,   and    helps   to   form    the   septum   of    the    nose. 

The  cribriform  plate  is  placed  above  the  vertical  plate, 
at  right  angles  to  it.     Its  upper  surface  forms  part  of 


Fig.  I. — Back  and  side 
view  of  the  ethmoid  bone, 
showing  in  B  the  lateral 
masses  on  either  side  of  the 
vertical  septal  plate  (2),  with 
which  they  are  united  by  the 
cribriform  plate  {3)  at  the 
base  of  the  crista  (i).  Be- 
tween the  nasal  meatus  and 
the  orbital  plate  (4)  are  the 
cells,  the  closure  of  many 
completed  by  the  frontal  and 
other  bones  articulating  with 
the  ethmoid  and  projecting 
downward  are  the  superior 
(6)  and  middle  (7)  turbinates 
and  the  uncinate  process  (s) 
(Allen). 


20  APPLIED  ANATOMY 

the  anterior  fossa  of  the  skull,  and  its  lower  surface  part 
of  the  roof  of  the  nose.  It  is  divided  into  two  lateral 
halves  by  the  crista  galli,  which  projects  into  the  anterior 
fossa,  being  a  continuation  upward  of  the  vertical  plate. 
The  cribriform  plate  is  perforated  by  numerous  foram- 
ina which  transmit  the  olfactory  nerve  filaments.  The 
two  lateral  masses  are  suspended  from  the  cribriform 
plate  on  either  side  of  the  vertical  plate.  Each  lateral 
mass  is  an  irregular  cube  in  shape,  and  is  composed  of 
the  middle  and  superior  turbinated  bones.  The  lateral 
surface,  known  as  the  os  planum,  is  flat  and  smooth,  and 
forms  part  of  the  inner  wall  of  the  orbit.  The  lateral 
mass  contains  the  middle  ethmoid  cells.  In  front, 
by  articulating  with  the  frontal  bone,  the  lateral  mass 
forms  the  anterior  ethmoid  cells,  and  behind,  by  articu- 
lating with  the  sphenoid  and  palate  bones,  the  posterior 
ethmoid  cells. 

The  ethmoid  bone  assists  in  forming  the  anterior  fossa 
of  the  skull,  the  nasal  chamber,  the  ethmoid  air-cells, 
the  maxillary  sinus,  and  the  orbit. 

•  The  Maxilla. — The  maxilla  (Fig.  5)  is  an  irregular 
pyramid  in  shape,  the  base  toward  the  median  Hne,  and 
the  apex  externally.  It  has  four  surfaces:  the  orbital, 
the  nasal,  the  lateral  or  facial,  and  the  zygomatic;  and 
four  processes:  the  nasal,  the  malar,  the  palatal,  and  the 
alveolar. 

The  orbital  or  upper  surface  assists  in  forming  the 
floor  of  the  orbit.  Immediately  beneath  it  runs  the 
infra-orbital  canal. 

The  nasal  surface  assists  in  forming  the  outer  wall  of 
the  nasal  chamber.  It  presents  the  large  opening  of 
the  maxillary  sinus. 


BOXES  21 

The  lateral  or  facial  surface  is  concave,  and  presents 
a  depression  behind  the  root  of  the  canine  tooth — the 
canine  fossa — and  the  infra-orbital  foramen. 

The  posterior  or  zygomatic  surface  assists  in  the  form- 
ation of  the  sphenomaxillary  and  zygomatic  fossae,  and 
presents  the  tuberosity,  a  rounded  prominence  above  the 
third  molar  tooth. 

The  body  of  the  maxilla  contains  the  maxillary  sinus 
or  antrum  of  Highmore. 

The  nasal  process  runs  upward  and  backward  from 
the  anterosuperior  angle  of  the  facial  surface,  and  assists 
in  forming  the  inner  wall  of  the  orbit  and  the  outer  wall 
of  the  nose. 

The  malar  process  projects  outward  and  upward  to 
articulate  with  the  malar  bone. 

The  palatal  process,  with  its  fellow  of  the  opposite 
side,  forms  the  anterior  three-fourths  of  the  hard  palate, 
the  remainder  being  formed  by  the  horizontal  process  of 
the  palate  bones  and  the  tips  of  the  pterygoid  processes 
of  the  sphenoid  bone.  In  the  anterior  portion  of  the 
hard  palate,  in  the  median  hne,  is  seen  the  anterior  pala- 
tine fossa.  This  contains  four  foramina — the  foramina 
of  Stenson,  situated  laterally,  and  the  foramina  of 
Scarpa,  situated  anteroposteriorly. 

The  alveolar  process  extends  forward  from  the  tuber- 
osity along  the  lower  border  of-  the  bone,  to  the  outer 
side  of  the  palatal  process,  and  meets  its  fellow  of  the 
opposite  side  at  the  median  line  in  front.  This  process 
is  composed  of  cancellated  or  spongy  bone,  and  contains 
alveoli  for  the  accommodation  of  the  roots  of  the  teeth. 
The  alveolar  process  has  an  inner  and  an  outer  plate, 
which    are    composed    of    dense    bone.     The    alveolar 


22 


APPLIED  ANATOMY 


process  is  developed  as  the  teeth  erupt,  and  undergoes 
absorption  when  they  are  lost. 

The  maxilla  assists  in  forming  the  following  cavities: 
the  orbit,  the  nasal  chamber,  the  mouth,  the  maxillary 
sinus,  the  sphenomaxillary  fossa,  and  the  zygomatic  fossa. 


letnporal- 


MassetSr 


Ze\fatb. 
labii  inferioriSi 

Meyator-\C- 
rtienti 


External  pterygoid 


Repressor  labii         „    '        JTlalysma. 
^  irtferiorJs  Repressor  anyulion 


Liternal. 
pieryc/oid. 

Genioh^o^lossus_ 
Geniohyoid^ 

Fig.  2. — The  mandible,  showing  muscular  attachments. 

The  Mandible. — The  mandible  (Fig.  2)  is  a  horseshoe- 
shaped  bone,  and  consists  of  a  horizontal  portion  called 
the  body,  and  two  rami.  The  body  extends  in  a  curved 
manner  on  either  side  of  the  median  line,  and  joins  each 
ramus  at  about  a  right  angle.  The  ramus  is  surmounted 
by  two  processes — the  coronoid  process  in  front,  for  the 


BONES  23 

insertion  of  the  temporal  muscle,  and  the  condyloid 
process  behind,  the  tip  of  which  articulates  with  the 
anterior  portion  of  the  glenoid  fossa  of  the  temporal 
bone,  forming  the  temporomandibular  joint.  The  two 
processes  are  separated  by  the  sigmoid  notch.  The 
outer  surface  of  the  bod}'  of  the  bone  presents  the  external 
obHque  hne  for  the  attachment  of  the  platysma  myoides. 
In  the  median  line  in  front,  at  the  symphysis,  is  the 
mental  process.  On  the  outer  surface,  below  and  be- 
tween the  premolar  teeth,  is  the  mental  foramen.  About 
the  middle  of  the  inner  surface  of  the  ramus  is  the  inferior 
dental  (mandibular)  foramen,  transmitting  the  inferior 
dental  nerve  and  vessels.  On  the  anterior  border  of  the 
foramen  is  a  sharp  spine,  the  hngula,  to  which  is  attached 
the  internal  lateral  ligament.  From  the  lower  border  of 
the  foramen  the  mylohyoid  groove  runs  forward  and  down- 
ward, transrnitting  the  mylohyoid  vessels  and  nerve. 
The  inner  surface  of  the  body  of  the  bone  presents  an 
oblique  line,  the  mylohyoid  ridge,  to  which  the  mylo- 
hyoid muscle  is  attached.  Below  the  ridge  posteriorly 
is  the  submaxillary  fossa,  which  contains  the  submaxillary 
gland,  while  above  it,  in  front,  is  the  sublingual  fossa, 
for  the  accommodation  of  the  sublingual  gland.  In  the 
median  line,  on  the  inner  surface,  are  the  four  genial 
tubercles — the  upper  pair  for  the  attachment  of  the 
geniohyoglossus  muscles,  and  the  lower  pair  for  the 
geniohyoid  muscles;  below  the  genial  tubercles  is  the 
digastric  fossa,  for  the  attachment  of  the  digastric 
muscle.  Just  in  front  of  the  angle  of  the  mandible,  on 
its  lower  border,  is  the  facial  notch,  through  which  passes 
the  facial  artery.  The  body  of  the  mandible  is  sur- 
mounted by  the  alveolar  process  and  the  teeth. 


24 


APPLIED  ANATOMY 


A  transverse  section  of  the  body  of  the  mandible  shows 
a  U-shaped  structure  of  dense  cortical  bone,  the  arms  of 
the  U  terminating  above  in  the  outer  and  inner  plates 
of  the  alveolar  process.  The  space  between  the  arms  of 
the  U  is  filled  with  fine  trabeculcC,  forming  the  cancellated 
structure.     The  roots  of  the  teeth  are  embedded  within 


Fig.  3. — Showing  cancellated  tissue  of  mandible  and  inferior  dental  tube, 
showing  direction  of  tube  from  mental  foramen  (Cryer). 


Wire 


this  cancellated  tissue.  Through  the  cancellated  tissue 
runs  the  inferior  dental  canal  or  cribriform  tube  of  the 
mandible,  which  forms  a  protective  passage  (Fig.  3) 
for  the  inferior  dental  nerve  and  vessels.  The  cribriform 
tube  passes  downward  and  forward  from  the  inferior 
dental  foramen  through  the  body  of  the  bone  to  the 
region  of  the  incisor  teeth.    From  this  point  a  recurrent 


BONES  .25 

branch  runs  backward  to  the  mental  foramen.  From  the 
cribriform  tube  smaller  tubules  pass  upward  and  forward 
in  a  curved  direction,  and  convey  indiA'idual  nerve-libers 
and  blood-vessels  to  the  roots  of  the  teeth.  The  tubules 
to  the  canine  and  the  lirst  premolar  are  given  off  from  the 
recurrent  portion  of  the  inferior  dental  tube. 

Drcclo pmcnt  and  Growth  of  the  Mandible. — The  mand- 
ible is  the  second  bone  in  the  body  to  be  developed, 
the  clavicle  being  the  first.  The  mandible  is  formed 
from  the  first  pair  of  branchial  folds,  called  the  mandib- 
ular plates.  These  plates,  at  about  the  twent}-fifth 
day  of  embryonic  life,  advance  from  either  side  and 
meet  in  the  median  line.  Soon  afterward  JMeckel's 
cartilage  is  formed  in  the  deeper  portion  of  the  mandibu- 
lar plate.  The  proximal  end  of  the  cartilage  forms  the 
malleus,  one  of  the  middle  ear  bones,  and  the  distal 
end  joins  its  fellow  of  the  opposite  side  in  the  median 
line  and  forms  the  mandible.  About  the  fortieth  day 
of  embryonic  life  ossification  begins  around  this  cartilage 
from  various  centers.  At  birth  there  is  no  osseous  union 
between  the  two  halves  of  the  mandible:  this  takes 
place  during  the  first  year. 

The  cortical  U-shaped  portion  of  the  bone  is  the 
framework  of  the  jaw.  It  increases  in  length  and  breadth 
in  a  different  manner  from  its  contents.  It  is  likely 
that  it  grows  by  an  interstitial  process,  each  half  having 
three  fixed  points  between  which  growth  occurs — 
the  ramus,  the  mental  foramen,  and  the  S}Tnphysis 
menti.  The  periods  of  growth  in  these  regions  seem  to 
correspond  with  the  time  of  development  and  eruption 
of  the  teeth  in  the  localities  concerned.  Thus,  the 
increase  between  the  mental  foramen  and  the  symphysis 


26  APPLIED  ANATOMY 

menti  occurs  during  the  time  the  incisor,  canine,  and 
premolar  teeth  are  developing,  while  the  greatest  growth 
from  the  mental  foramen  to  the  ramus  takes  place 
during  the  development  of  the  molar  teeth. 

The  contents  of  the  U-shaped  portion  grow  forward 
as  the  cortical  structure  increases  in  length.  It  is  this 
forward  movement  that  gives  the  curvature  to  the  vari- 
ous small  tubes  "to  the  roots  of  the  teeth. 

At  birth  the  angle  of  the  mandible  is  very  obtuse, 
the  ramus  and  body  being  almost  in  a  straight  line.  As 
the  teeth  erupt  the  angle  changes,  until,  at  the  age  whdn 
all  the  permanent  teeth  are  in  position,  it  nearly  ap- 
proaches a  right  angle.  The  change  is  due  to  the  grad- 
ual separation  of  the  upper  and  lower  jaws  by  the  growth 
of  the  teeth  and  alveolar  process.  As  the  teeth  are 
lost  with  age  the  angle  returns  to  its  former  condition, 
again  becoming  obtuse.  This  senile  change  can  be 
greatly  retarded  by  replacing  the  lost  teeth  by  artificial 
dentures. 

The  Hyoid  Bone. — The  hyoid  bone,  or  os  Hnguae, 
while  not  a  bone  of  the  skull,  is  so  closely  associated 
with  the  mouth  and  jaws  by  attachment  of  muscles 
that  it  should  be  described  in  a  study  of  the  regional 
anatomy  of  these  parts.  The  hyoid  bone  is  a  sym- 
metric, horseshoe-shaped  bone,  situated  in  the  median 
line  of  the  upper  part  of  the  neck,  beneath  the  floor 
of  the  mouth,  and  above  the  larynx.  It  is  a  floating 
bone,  having  no  articulation.  It  consists  of  a  body 
and  four  processes,  the  greater  and  lesser  cornua  on  each 
side.  The  body  of  the  hyoid  bone  is  quadrilateral  in 
shape,  compressed  from  before  backward,  and  extends 
symmetrically   on   each   side  of   the  median   line.    It 


BONES 


27 


gives  attachment  to  the  geniohyoid,  mylohyoid,  stylo- 
hyoid, digastric,  hyoglossus,  geniohyoglossus,  sterno- 
hyoid, omohyoid,  and  thyrohyoid  muscles,  and  the 
thyrohyoid  membrane. 


Fig.  4. — Anlcrolateriil  \icvv  of  skull  (Cryer). 

The  greater  cornu  projects  backward  from  the  body 
of  the  bone,  giving  attachment  to  the  superior  constrictor 
of  the  pharynx,  the  hyoglossus,  and  the  thyrohyoid 
muscles. 

The  lesser  cornu  is  shorter  than  the  greater  cornu,  and 


28 


APPLIED  ANATOMY 


projects  backward  and  upward  from  the  body  of  the 
bone,  giving  attachment  to  the  stylohyoid  hgament. 


The  Skull  as  a  Whole 

Anterior  Region. — The  following  prominent  landmarks 
are  seen  in  an  anterior  view  of  the  skull  (Fig.  4) : 
The  supra-orbital  portion  of  the  frontal  bone,  the  orbit, 
the  nasal  fossa,  the  malar  bone,  continued  laterally  as 


BREGMA 


FRONTAL 


GLABELLA    ^*  \>  '^0/f_^  \^ 

■?  •^/"'WSI  OBELION 

NASION  J\    m  it.,-r^ "^""V.-,         '  ^\  ""^ 

1/      IS&/        i&        /    TEMPORAL      \  "    J^  lambda 


Fig.  5.— Side  view  of  skull  (Sobotta  and  McMurrich). 

the  zygoma,  the  maxilla,  the  teeth,  and  the  anterior 
portion  of  the  mandible,  with  the  mental  process  in 
front.  The  three  most  prominent  foramina  seen  are 
the  supra-orbital  in  the  frontal  bone,  the  infra-orbital 
in  the  maxilla,  and  the  mental  in  the  mandible.  These 
three  foramina  are  in  a  vertical  straight  line. 

Lateral  View.— The  lateral  aspect  of  the  skull  (Fig. 
5)  presents  the  mastoid  process,  the  external  auditory 


BONES  29 

meatus,  the  auditory  process,  the  glenoid  fossa,  the 
zygomatic  arch,  the  temporal  fossa,  the  zygomatic 
fossa,  the  condyloid  and  coronoid  processes  of  the 
mandible.  The  principal  sutures  seen  are  the  lambdoid, 
between  the  occipital  and  parietal  bones,  the  squamous, 
between  the  temporal  and  parietal  bones,  and  the  coro- 
noid, between  the  frontal  and  parietal  bones.  Certain 
prominent  points  of  the  skull  have  been  given  special 
names  for  convenience.  These  are  shown  in  the  illus- 
tration. 

BASE  OF  THE   SKULL 

Inferior  or  External  Surface  (Hg.  6). — This  surface 
presents  from  before  backward  the  hard  palate,  sur- 
rounded by  the  upper  teeth,  the  zygomatic  arch,  the 
pterygoid  process  of  the  sphenoid,  the  posterior  nares, 
the  pterygoid  fossa,  the  eminentia  articularis,  the  glenoid 
fossa,  the  tympanic  plate,  the  styloid  process,  the 
mastoid  process,  the  petrous  portion  of  the  temporal 
bone,  the  basilar  and  condyloid  processes  of  the  occipital 
bone,  and  the  external  occipital  protuberance.  The 
important  foramina  seen  are:  the  anterior,  posterior, 
and  accessory  palatine  foramina,  the  foramen  ovale, 
the  foramen  spinosum,  carotid,  middle  lacerated,  stylo- 
mastoid, posterior  lacerated  or  jugular,  anterior  and 
posterior  condyloid,  and  foramen  magnum. 

The  internal  or  upper  surface  of  the  base  of  the  skull 
is  divided  into  three  fossae— the  anterior,  middle,  and 
posterior  fossae  of  the  skull  (Fig.  7). 

The  anterior  fossa  presents  the  cribriform  plate  and 
the  crista  galli  of  the  ethmoid  bone,  the  orbital  plate 
of  the  frontal  bone,  and  the  body  and  lesser  wing  of  the 
sphenoid  bone,  at  the  junction  of  which  is  the  anterior 


30 


APPLIED  ANATOMY 


O   OJ 
O.  O 


SI     Ph     Ph     Ph 


W  pqOHftic/i    US 


fa 


BONES 


31 


32  APPLIED  ANATOMY 

clinoid  process.  The  middle  clinoid  process  is  given  off 
from  the  side  of  the  body  of  the  sphenoid.  The  foramina 
seen  are:  the  orifices  for  the  olfactory  nerves,  the  nasal 
slit,  the  anterior  and  posterior  ethmoid  foramina,  and 
the  optic  foramen. 

The  middle  fossa  is  composed  of  the  body  and  greater 
wing  of  the  sphenoid  bone,  the  anterior  surface  of  the  pe- 
trous portion,  and  the  squamous  portion  of  the  temporal 
bone.  In  it  are  seen  the  sella  turcica,  the  depression  for 
the  Gasserian  ganglion,  the  anterior  lacerated  foramen 
or  sphenoid  fissure,  the  foramen  rotundum,  the  foramen 
ovale,  the  foramen  spinosum,  the  middle  lacerated  for- 
amen, and  the  orifice  of  the  carotid  canal. 

The  posterior  fossa  is  made  up  of  the  basilar  process 
of  the  occipital,  at  the  anterior  end  of  which  is  the  pos- 
terior clinoid  process,  the  horizontal  portion  of  the 
occipital  bone,  and  the  posterior  surface  of  the  petrous 
portion  of  the  temporal  bone.  It  presents  the  internal 
auditory  meatus,  the  posterior  lacerated  or  jugular 
foramen,  the  anterior  and  posterior  condyloid  foramina, 
and  the  foramen  magnum. 

The  Orbit 

The  orbit  is  a  quadrilateral  pyramid  in  shape,  its 
base  being  directed  forward  and  a  little  outward.  Seven 
bones  enter  into  its  formation,  viz.:  frontal,  sphenoid, 
ethmoid,  palate,  malar,  maxilla,  and  lacrimal. 

The  roof  of  the  orbit  is  composed  of  the  orbital  plate 
of  the  frontal  bone  and  part  of  the  lesser  wing  of  the 
sphenoid  bone. 

The  floor  is  made  up  of  the  orbital  surface  of  the  maxilla 
and  the  orbital  processes  of  the  malar  and  palate  bones. 


BONES  33 

The  outer  wall  is  formed  by  the  orbital  surface  of  the 
greater  wing  of  the  sphenoid  and  part  of  the  malar  bone. 

The  inner  wall  is  formed  by  the  nasal  process  of  the 
maxilla,  the  os  planum  of  the  ethmoid,  and  the  lacrimal 
bone. 

The  openings  into  the  orbit  are  ten  in  number,  as 
follows:  Optic  foramen,  at  the  apex,  transmitting  the 
optic  nerve  and  the  ophthalmic  artery.  Sphenoid 
fissure,  near  the  apex,  transmitting  the  third,  fourth, 
ophthalmic  division  of  the  fifth,  and  sixth  nerves,  and  the 
ophthalmic  vein.  The  anterior  ethmoid  foramen  on  the 
inner  wall,  transmitting  the  nasal  nerve  and  anterior 
ethmoid  vessels.  The  posterior  ethmoid  foramen,  on 
the  inner  wall,  transmitting  the  posterior  ethmoid 
vessels.  The  lacrimonasal  canal  has  its  opening  at  the 
anterior  portion  of  the  inner  side  of  the  orbit,  and  com- 
municates with  the  inferior  meatus  of  the  nose.  The 
infra-orbital  canal  begins  in  the  floor  of  the  orbit,  and 
transmits  the  infra-orbital  nerve  and  vessels.  The 
sphenomaxillary  fissure  is  in  the  posterior  portion  of  the 
orbital  cavity,  and  transmits  the  infra-orbital  nerve  and 
vessels.  The  malar  foramina,  two  in  number,  are  in  the 
outer  wall  of  the  orbit,  and  transmit  nerves  and  vessels 
to  the  cheek. 

Bony  Roof  of  the  Mouth 

The  bony  roof  of  the  mouth  comprises  the  hard  palate; 
the  anterior  three-fourths  are  made  up  of  the  palatal 
processes  of  the  maxilla;,  and  the  posterior  one-fourth 
by  the  horizontal  plates  of  the  palate  bones.  At  the 
posterior  margin  of  the  latter  externally  are  the  hamular 
processes  of  the  sphenoid  bone.     The  palatal  processes 

3 


34  APPLIED  ANATOMY 

of  the  maxilla  are  formed  from  three  processes,  the 
wedge-shaped  intermaxillary  bone  in  front  containing 
the  germs  of  the  incisor  teeth,  and  the  two  lateral 
processes  or  true  maxillae.  The  intermaxillary  bone  is 
formed  by  the  union  of  the  right  and  left  premaxillary 
bones,  which  in  early  hfe  are  separated  by  a  suture.  The 
orthodontist  in  certain  cases  is  able  to  open  this  suture  in 
the  process  of  widening  the  dental  arch. 

In  the  anterior  portion  of  the  hard  palate,  at  the  junc- 
tion of  the  palatal  processes  of  the  maxillae  and  the  inter- 
maxillary bone,  is  the  anterior  palatine  fossa,  which 
contains  four  openings,  two  being  the  foramina  of 
Scarpa,  situated  anteroposteriorly,  and  transmitting  the 
nasopalatine  nerves,  and  two  situated  laterally,  the 
foramina  of  Stenson,  transmitting  the  anterior  palatine 
vessels.  In  the  suture  between  the  maxilla  and  the 
palate  bone  are  the  posterior  and  accessory  palatine 
canals,  for  the  transmission  of  the  posterior  palatine 
nerves  and  vessels. 

The  Nasal  Fossae 

The  nasal  fossae,  two  in  number,  are  situated  one  on 
either  side  of  the  median  line  of  the  face,  separated  by 
a  thin  plate  of  bone — the  nasal  septum.  The  nasal 
fossae  are  composed  of  a  roof,  a  floor,  a  septum,  and 
outer  walls. 

The  roof  of  the  nasal  fossas  consists  of  three  portions 
—anterior,  middle,  and  posterior.  The  anterior  por- 
tion extends  upward  and  backward,  and  is  composed  of 
the  under  surfaces  of  the  nasal  bones  and  the  nasal 
spine  of  the  frontal  bone.  The  middle  portion  is  hori- 
zontal, and  is  composed  of  the  cribriform  plate  of  the 


£OiVES 


35 


36  APPLIED  ANATOMY 

ethmoid  bone.  The  posterior  portion  slopes  downward 
and  backward,  and  is  composed  of  the  body  of  the  sphe- 
noid and  the  alae  of  the  vomer. 

The  floor  of  the  nose  is  formed  by  the  palatal  processes 
of  the  maxillae  in  front  and  the  horizontal  processes  of 
the  palate  bones  behind. 

The  septum  of  the  nose  lies  vertically  in  the  median 
line  and  runs  in  an  anteroposterior  direction.  The 
principal  structures  forming  it  are  the  vomer  behind  and 
below,  the  vertical  plate  of  the  ethmoid  in  front  and 
above,  while  in  the  recent  state  a  triangular  notch  in 
front  is  filled  in  with  the  triangular  cartilage.  In  addi- 
tion, the  crests  of  the  maxillary  and  palate  bones,  the 
rostrum  of  the  sphenoid,  and  the  nasal  spine  of  the 
frontal  bones  assist  in  forming  the  nasal  septum  (Fig.  8). 

The  bones  entering  into  the  formation  of  the  lateral 
wall  of  the  nasal  chamber  are :  the  nasal,  the  nasal  process 
of  the  maxillary,  the  lacrimal,  the  ethmoid,  the  inferior 
turbinated,  the  palate,  and  the  pterygoid  process  and 
body  of  the  sphenoid. 

The  inferior  turbinated  bone  and  the  turbinated 
processes  of  the  ethmoid  bone  divide  the  lateral  wall  of 
the  nasal  chamber  into  several  horizontal  compartments 
or  meati,  three  being  the  number  usually  described. 
In  the  majority  of  skulls,  however,  four  meati  are  present, 
and  in  a  few  cases  five  or  even  six  have  been  found. 
The  several  meati  have  communications  with  the  maxil- 
lary sinus  and  other  pneumatic  spaces  (Fig.  9) . 

The  inferior  meatus  is  situated  between  the  floor  of  the 
nose  and  the  inferior  turbinated  bone.  Into  it  opens 
the  lacrimonasal  duct,  which  conveys  tears  from  the 
orbit. 


BONES 


17 


Fig.  g. — An  anteroposterior  section  within  the  nasal  chamber,  with  the  middle 
turbinate  bone  and  portion  of  ceil  walls  turned  up  (Cryer). 


The  middle  meatus  is  found  betweeji  the  inferior  and^i 
middle  turbinated  bones.  Into  'it  open  the  •maxillary-' 
sinus,  the  frontal  sinus,  and  the  anterior  and  middle^ 


38  APPLIED  ANATOMY 

ethmoid  cells.  All  these  air-spaces  open  into  the 
middle  meatus  through  the  hiatus  semilunaris,  a  semi- 
circular groove  continuous  with  the  infundibulum,  which 
is  the  outlet  of  the  frontal  sinus.  Many  authorities 
do  not  regard  the  infundibulum  as  distinct  from  the 
hiatus  semilunaris,  the  so-called  infundibulum  being, 
in  their  opinion,  the  upper  part  of  the  hiatus.  The 
narrow  opening  from  the  frontal  sinus  into  the  hiatus 
semilunaris  or  infundibulum  is  sometimes  known  as  the 
ostium  frontale.  The  hiatus  semilunaris  is  bounded 
toward  the  median  line  by  the  unciform  process  of  the 
ethmoid  bone,  this  hook-like  projection  overlapping  the 
ostium  maxillare,  which  is  the  opening  into  the  maxillary 
sinus.  Above  the  unciform  process  is  the  bulla  ethmoid- 
alis,  a  rounded  prominence  of  bone  formed  by  the 
bulging  of  the  middle  ethmoid  cells.  The  parts  just 
described,  the  unciform  process,  the  hiatus  semilunaris, 
and  the  bulla  ethmoidalis,  are  hidden  from  view  by  the 
middle  turbinated  bone,  and  can  usually  be  seen  only 
by  removing  the  latter. 

The  superior  meatus  is  situated  between  the  middle 
and  superior  turbinated  bones,  which  are  both  parts  of 
the  ethmoid.  When  only  three  meati  are  present,  the 
sphenoid  sinus,  the  posterior  ethmoid  cells,  and  the 
cell  in  the  orbital  process  of  the  palate  bone,  all  open  into 
this  meatus,  but  when  there  are  four  meati,  the  sphe- 
noid sinus  and  the  posterior  ethmoid  cells  open  into  the 
fourth  or  supreme  meatus.  The  sphenoid  cells  especially, 
in  the  majority  of  cases,  open  into  the  highest  meatus, 
whether  three,  four,  or  five  meati  be  present.  When 
more  than  three  meati  exist,  they  are  formed  by  addi- 
tional turbinated  masses  on  the  ethmoid  bone. 


BONES  39 

The  nasal  chambers  are  bound  in  front  by  the 
anterior  nares,  and  behind  by  the  posterior  nares.  The 
space  of  the  anterior  nares  is  inclosed  by  the  nasal  bones 
above,  the  maxillae  laterally  and  below,  while  it  is  divided 
into  two  portions  by  the  triangular  cartilage  of  the  nasal 
septum. 

The  posterior  nares  is  bounded  above  by  the  cribri- 
form plate  of  the  ethmoid  and  body  of  the  sphenoid 
bones,  laterally  by  the  vertical  plates  of  the  palate  bones, 
and  below  by  the  horizontal  plates  of  the  palate  bones. 
The  vomer  divides  the  space  vertically  into  two  portions. 

The  Maxillary  Sinus 

The  maxillary  sinus  or  antrum  of  Highmore  (Fig.  lo) 
is  the  largest  pneumatic  space  communicating  with  the 
nasal  fossa,  and  is  situated  in  the  body  of  the  maxillary 
bone.  In  the  typical  specimen  the  cavity  is  somewhat 
pyramidal  in  shape,  with  its  base  directed  toward  the 
nasal  fossa,  and  its  apex  extending  toward  and  sometimes 
into  the  malar  bone.  Though  this  may  be  given  as  the 
t>pical  shape,  yet  the  maxillary  sinus  varies  very  much 
in  form  and  size  in  different  individuals,  and  on  the  two 
sides  in  the  same  individual.  The  cavity  is  lined  with 
mucoperiosteum  surmounted  by  a  layer  of  ciliated  col- 
umnar epithelium. 

The  roof  of  the  maxillary  sinus  is  formed  by  the  orbital 
plate  of  the  maxillary  bone,  which  separates  it  from  the 
orbit.  It  presents  a  ridge  of  bone  inclosing  the  canal  for 
the  passage  of  the  infra-orbital  vessels  and  nerve.  The 
prominence  of  this  ridge  varies  in  different  subjects.  In 
the  negro  race  especially,  where  the  bones  are  very  thick, 
it  is  scarcely  perceptible. 


40 


APPLIED  ANATOMY 


The  anterior  wall  is  formed  by  the  facial  portion  of  the 
maxilla.  It  contains  the  anterior  dental  canal,  trans- 
mitting nerves  and  vessels  to  the  incisor  teeth. 

The  floor  of  the  maxillary  sinus  is  composed  of  the 


\  rontal 
binus 


Fig.  lo. — Transverse  section  of  face,  showing  probe  passing  from  maxillary  sinus 
through  ostium  maxillare  and  liiatus  semilunaris  into  frontal  sinus  (Cryer). 

alveolar  process.  It  presents  conic  elevations  corres- 
ponding to  the  apices  of  the  roots  of  the  molar  and  some- 
times of  the  premolar  teeth.  It  may  also  present  partial 
septa  extending  transversely.  Complete  septa  are  never 
found  in  the  maxillary  sinus. 


BONES 


41 


The  posterior  wall  of  the  maxillary  sinus  is  formed  by 
the  zygomatic  plate  of  the  maxilla,  which  separates  it 
from  the  sphenomaxillary  fossa. 

The  proximal  or  nasal  wall  is  formed  chiefly  by  the 
maxilla,  aided  by  the  inferior  turbinated,  ethmoid,  and 
palate  bones  (Fig.  11).      This  partition  separates  the 


Fig.  11. — Anteroposterior  division  throuRh  the  maxillary  sinus  (Cryer). 

maxillary  sinus  fro'm  the  nasal  fossa.  At  the  upper  ante- 
rior portion  of  this  wall  is  found  an  oval  foramen — the 
ostium  maxillare — which  affords  communication  between 
the  maxillary  sinus  andnniddle  meatus,  opening  directly 
into  the  hiatus   semilunaris.     This  is  the  only  normal 


42  APPLIED  ANATOMY 

opening  of  the  antrum  of  Highmore,  but  in  certain 
pathologic  conditions  more  than  one  opening  may  be 
present,  when  the  normal  opening  becomes  closed  by 
pressure  of  the  engorged  mucous  membrane  covering  the 


Fig.  12. — Front  view  of  skull  with  frontal  sinuses  exposed  (Cryer). 

bulla  ethmoidalis.  Under  normal  conditions  there  is 
communication  between  the  maxillary  sinus  and  the 
frontal  sinus  through  the  ostium  maxillare,  the  hiatus 
semilunaris,  and  the  ostium  frontale.  By  this  com- 
munication disease  from  the  teeth  may  spread  through 
the  antrum  to  the  frontal  sinus  and  the  other  pneumatic 

spaces. 

The  Frontal  Sinuses 

The  frontal   sinuses  (Fig.  12)  are  two  irregular  air- 
cells  situated  in  the  facial  portion  and  the  orbital  proc- 


BONES  43 

esses  of  the  frontal  bone.  They  vary  greatly  in  size, 
shape,  and  position,  and  there  may  be  three,  four,  or 
five  cells,  each  wath  a  separate  opening.  Each  frontal 
sinus  is  separated  from  its  fellow  by  a  bony  septum, 
which  may  be  in  the  median  line  or  to  one  side  of  it. 
Partial  septa  also  often  exist.  In  typical  cases  the  frontal 
sinus  opens  at  its  lower  part  into  the  hiatus  semilunaris 
of  the  middle  meatus  of  the  nose.  The  opening  is 
known  as  the  ostium  frontale.  Multiple  sinuses  may 
open  into  one  another  or  into  the  anterior  ethmoid  cells. 

The  sphenoid  sinuses  are  two  in  number,  situated 
in  the  body  of  the  sphenoid  bone.  The  bony  septum 
between  them  is  often  deflected  to  one  side  or  the  other. 
They  empty  into  the  highest  meatus  of  the  nose. 

The  ethmoid  air-cells  occupy  the  lateral  masses  of  the 
ethmoid  bone,  and  are  divided  into  three  sets — anterior, 
middle,  and  posterior.  The  anterior  and  middle  eth- 
moid cells  open  into  the  middle  meatus  of  the  nose 
through  the  hiatus  semilunaris,  while  the  posterior 
ethmoid  cells  empty  into  the  superior  meatus. 
Review  Questions 

Name  the  bones  forming  the  cranium. 
Name  the  bones  forming  the  face. 
Describe  the  princ  ipal  portions  of  the  sphenoid  bone. 
Describe  the  ethmoid  bone. 

What  cavities  does  the  ethmoid  bone  assist  in  forming? 
Describe  the  maxilla. 

What  cavities  does  the  maxilla  assist  in  forming? 
Describe  the  general  features  of  the  mandible. 
Describe  the  external  surface  of  the  mandible. 
Describe  the  internal  surface  of  the  mandible. 
Describe  the  internal  structure  of  the  mandible. 
Describe  in  a  general  way  the  development  and  growth  of  the  mandible. 
Describe  the  variations  occurring  in  the  angle  of  the  mandible  accord- 
ing to  the  age  of  the  individual. 
Dcs<  ribc  the  hyoid  bom-. 


44  APPLIED  ANATOMY 

What  prominent  landmarks  are  seen  in  an  anterior  view  of  the  skull? 

What  prominent  landmarks  are  seen  in  a  lateral  view  of  the  skull? 

What  prominent  landmarks  are  seen  on  the  under  surface  of  the  base 
of  the  skull? 

What  prominent  landmarks  are  seen  on  the  upper  surface  of  the  base 
.  of  the  skull? 

Name  the  bones  forming  the  orbit,  giving  their  relations. 

Name  the  openings  into  the  orbit,  giving  the  structures  that  pass 
through  each. 

Describe  the  bony  roof  of  the  mouth,  naming  the  bones  forming  it, 
and  giving  their  relations. 

What  foramina  are  found  in  the  roof  of  the  mouth?  What  structures 
do  they  transmit? 

Name  the  teeth  which  develop  in  the  different  formative  bones  of  the 
upper  jaw. 

Name  the  bones  forming  the  roof  of  the  nasal  fossae,  giving  their 
relations. 

Give  the  names  and  position  of  the  bones  forming  the  floor  of  the  nose. 

Describe  the  nasal  septum,  giving  the  bones  forming  it. 

Name  the  bones  forming  the  lateral  wall  of  the  nasal  chamber.. 

Describe  the  various  meati  of  the  nose. 

Name  the  openings  into  the  various  meati  of  the  nose. 

Describe  the  hiatus  semilunaris  and  the  adjacent  structures. 

What  bones  bound  the  anterior  nares? 

What  bones  bound  the  posterior  nares? 

In  what  bone  is  the  antrum  of  Highmore  situated? 

Describe  the  shape  and  boundaries  of  the  maxillary  sinus. 

Name  and  give  the  situation  of  the  outlet  of  the  maxillary  sinus. 

Trace  the  course  of  disease  from  the  maxillary  sinus  to  the  frontal 
sinus. 

Give  the  general  situation  and  outlet  of  the  frontal  sinus. 


CHAPTER  II 

THE  TEMPOROMANDIBULAR  ARTICULATION 

The  temporomandibular  joint  is  formed  by  the 
articulation  of  the  condyle  of  the  mandible  with  the 
glenoid  fossa  of  the  temporal  bone.  It  is  a  compound 
joint,  allowing  elevation  and  depression  of  the  mandible, 
forward  and  backward  gliding,  and  also  lateral  motion. 

The  condyle  of  the  mandible  is  the  rounded  prominence 
surmounting  the  condyloid  process.  The  condyle  is 
broader  in  its  lateral  direction  than  anteroposteriorly, 
and  is  covered  with  articular  cartilage. 

The  glenoid  fossa  is  a  shallow  depression  in  the 
temporal  bone,  situated  just  in  front  of  the  ear.  It 
is  bounded  in  front  by  a  ridge — the  eminentia  articularis 
— and  posteriorly  by  the  tympanic  plate  of  the  temporal 
bone.  The  fossa  is  divided  into  an  anterior  portion  and 
a  posterior  portion  by  the  Glaserian  fissure,  which 
contains  the  processus  gracihs  of  the  malleus,  and 
transmits  the  tympanic  branch  of  the  internal  maxillary 
artery.  The  anterior  part  of  the  glenoid  fossa  is  the 
articular  portion.  The  posterior-  portion  contains  a 
process  of  the  parotid  gland. 

There  are  four  ligaments  connected  with  this  joint, 
and  also  an  interarticular  fibrocartilage  with  two  syn- 
ovial sacs. 

The  ligaments  are  as  follows: 

1.  Capsular  ligament. 

2.  External  lateral  ligament. 

45 


46  APPLIED  ANATOMY 

3.  Internal  lateral  ligament  (sphenomandibular) . 

4.  Stylomandibular  ligament. 

The  capsular  ligament  surrounds  the  joint  and  is  at- 
tached above  to  the  margins  of  the  glenoid  fossa,  and 
below  to  the  neck  of  the  condyle.  It  also  sends  fibers 
in  to  blend  with  the  interarticular  fibrocartilage. 

The  external  lateral  ligament  is  a  thickening  of  the 
capsular  ligament,  and  extends  from  the  tubercle  of  the 
zygoma  to  the  outer  side  of  the  neck  of  the  condyle. 

The  internal  lateral  ligament  runs  from  the  spine  of 
the  sphenoid  to  the  lingula  of  the  mandible. 

The  stylomandibular  ligament  runs  from  the  tip  of 
the  styloid  process  of  the  temporal  bone  to  the  angle  of 
the  mandible. 

The  interarticular  fibrocartilage  is  an  oval  disc, 
convex  above  and  concave  below,  thicker  at  its  periphery 
than  centrally,  placed  between  the  condyle  and  the 
glenoid  fossa.  It  is  held  in  place  by  fibers  from  the 
capsular  ligament,  and  also  receives  a  slip  from  the 
external  pterygoid  muscle,  which  draws  it  forward  on 
the  eminentia  articularis  when  the  jaw  is  protruded. 

The  synovial  sacs,  containing  synovial  fluid,  are  two 
in  number,  situated  one  above  and  one  below  the  inter- 
articular fibrocartilage. 

Review  Questions 

Describe  the  bony  surfaces  forming  the  temporomandibular  joint. 
Describe  the  h'gaments  and  other  structures  of  the  joint. 


CHAPTER  III 

MUSCLES  AND  FASCIA 

The  Cervical  Fascia 

The  cervical  fascia  is  divided  into  the  superficial  and 
the  deep  layers.  The  superficial  cervical  fascia  hes 
immediately  beneath  the  skin,  and  connects  the  latter 
with  the  deeper  structures.  In  its  meshes  is  found  the 
platysma  myoides,  a  broad,  thin  sheet  of  muscle  extend- 
ing from  the  clavicle  to  the  lower  border  of  the  mandible, 
where  it  blends  with  the  muscles  of  expression  about  the 
mouth.  Through  the  superficial  fascia  run  the  external 
anterior  and  posterior  external  jugular  veins  and  the 
superficial  cervical  nerves. 

The  deep  cervical  fascia  or  cravat  fascia  forms  a 
complete  investment  for  the  deeper  structures  of  the 
neck.  It  is  attached  behind  to  the  spinous  processes 
of  the  cervical  vertebrae,  splits  into  two  layers  to  invest 
the  trapezius  muscle,  and  forms  a  single  layer  at  the- 
anterior  border  of  that  muscle,  to  cross  the  posterior 
triangle  of  the  neck.  When  the  posterior  border  of  the 
sternomastoid  muscle  is  reached,  the  fascia  again  divides 
into  two  layers,  one  going  in  front  of  and  one  behind  the 
muscle.  From  the  anterior  Vjorder  of  the  sternomastoid 
a  single  layer  passes  across  the  anterior  triangle  to 
meet  the  fascia  of  the  opposite  side  in  the  median  line  of 

47 


48  APPLIED  ANATOMY 

the  neck.  The  cervical  fascia  is  attached  below  to  the 
clavicle.  Above,  it  is  attached  to  the  lower  border  of 
the  mandible,  the  zygoma,  the  mastoid  process,  and  the 
superior  curved  line  of  the  occipital  bone.  This  fascia 
gives  off  many  processes  which  invest  various  structures 
of  the  neck.  Two  layers  are  given  off  to  invest  the 
parotid  gland,  known  as  the  parotid  fascia.  The  follow- 
ing are  the  deeper  processes:  (i)  A  process  comes  off  near 
the  anterior  border  of  the  sternomastoid  muscle,  which 
passes  behind  the  depressor  muscles  of  the  hyoid  bone, 
invests  the  thyroid  gland,  and  covers  the  front  of  the 
trachea.  (2)  A  process  known  as  the  prevertebral  fascia 
passes  behind  the  trachea  and  esophagus  and  in  front 
of  the  prevertebral  miiscles.  (3)  The  carotid  sheath,  in- 
closing the  carotid  artery,  the  internal  jugular  vein,  and 
the  pneumogastric  nerve,  is  derived  from  layers  i  and  2. 

The  Surgical  Square  and  Triangles  of  the  Neck 

The  surgical  square  of  the  neck  is  bounded  in  front 
by  the  median  line;  behind,  by  the  anterior  border  of  the 
trapezius  muscle;  above,  by  the  lower  border  of  the  man- 
dible and  a  line  drawn  from  the  angle  of  the  mandible 
to  the  mastoid  process  of  the  temporal  bone;  below,  by 
the  clavicle.  The  coverings  of  the  square  of  the  neck  are 
the  skin,  the  superficial  fascia, — in  which  lies  the  pla- 
tysma  myoides, — and  the  deep  fascia. 

The  sternocleidomastoid  muscle  runs  diagonally 
across  the  square  of  the  neck,  from  its  posterior  superior 
angle  to  its  anterior  inferior  angle,  dividing  it  into  an 
anterior  and  a  posterior  triangle  (Fig.  13). 

The  anterior  triangle  is  divided  into  three  smaller 
triangles  by  the  anterior  and  posterior  bellies  of  the 


MUSCLES  AND   FASCTM 


49 


digastric  muscle  and  the  anterior  belly  of  the  omohyoid 
muscle,  which  traverses  the  square  diagonally  from  its 
anterosuperior  to  its  postero-inferior  angle.  The  three 
anterior  triangles  are  the  inferior  carotid,  the  superior 
carotid,  and  the  submaxillary  triangles. 

The  posterior  triangle  of  the  neck  is  divided  by  the 
posterior  belly  of  the  omohyoid  muscle  into  the  sub- 
clavian and  occipital  triangles. 


Fig.  13. — Triangles  of  the  neck:  A,  Submaxillan,' triangle;  B,  superior  car- 
otid triangle;  C,  inferior  carotid  triangle;  D,  occipital  triangle;  E,  supraclavic- 
ular triangle  (Campl/ell). 

The  inferior  carotid  triangle  is  bounded  in  front  by  the 
median  line,  behind  by  the  sternomastoid  muscle,  and 
above  by  the  anterior  belly  of  the  omohyoid  muscle. 
It  contains  the  common  carotid,  the  inferior  thyroid, 
and  the  vertebral  arteries,  the  internal  jugular  and  middle 
and  inferior  thyroid  veins,  and  the  pneumogastric  and 
phrenic  nerves. 

The  superior  carotid  triangle  is  bounded  in  front  by 


50  APPLIED  ANATOMY 

the  anterior  belly  of  the  omohyoid  muscle,  above  by 
the  posterior  belly  of  the  digastric  muscle,  and  behind 
by  the  sternomastoid  muscle.  It  contains  the  common 
carotid  and  its  bifurcation  into  the  internal  and  external 
carotid  arteries,  the  superior  thyroid,  the  ascending 
pharyngeal,  the  Hngual,  the  facial,  the  occipital,  and  the 
posterior  auricular  arteries;  the  superior  thyroid,  the 
ranine,  the  lingual,  the  facial,  and  the  internal  jugular 
veins,  and  the  descendens  hypoglossi  and  pneumo- 
gastric  nerves. 

The  submaxillary  triangle  is  bounded  below  by  the 
anterior  and  posterior  bellies  of  the  digastric  muscle, 
and  above  by  the  lower  border  of  the  mandible  and  a 
line  drawn  from  the  angle  of  the  mandible  to  the  mastoid 
process.  This  triangle  contains  the  external  carotid, 
the  facial,  the  lingual,  and  the  posterior  auricular 
arteries;  the  internal  jugular,  the  lingual,  and  the  facial 
veins;  the  pneumogastric,  the  glossopharyngeal,  and  the 
hypoglossal  nerves,  and  the  submaxillary  gland.  The 
submaxillary  triangle  is  the  most  important  to  the  oral 
surgeon  and  the  dentist,  because  it  lies  immediately 
beneath  the  oral  cavity,  and  is  most  often  affected  by 
diseases  of  the  mouth. 

The  occipital  triangle  is  bounded  in  front  by  the  sterno- 
mastoid muscle,  behind  by  the  anterior  border  of  the 
trapezius,  and  below  by  the  posterior  belly  of  the  omo- 
hyoid muscle.  It  contains  the  transversalis  colli  artery 
and  the  spinal  accessory  and  cervical  plexus  of  nerves. 

The  subclavian  triangle  is  bounded  below  by  the  cla,vicle, 
in  front,  by  the  sternocleidomastoid  muscle,  and  behind, 
by  the  posterior  belly  of  the  omohyoid  muscle.  It 
contains   the   subclavian,    the   vertebral,    the   thyroid 


MUSCLES  AND  FASCIA  5  I 

axis,  the  internal  mammary,  and  the  superior  inter- 
costal arteries,  the  subclavian  vein,  and  the  brachial 
plexus  of  nerves. 

The  Tongue 

The  tongue,  when  the  mouth  is  closed,  "  occupies 
the  space  from  the  anterior  teeth  backward  nearly  to 
the  postpharyngeal  wall,  and  from  the  floor  of  the 
mouth  nearly  to  the  roof.  It  almost  completely  fills 
the  space,  which  is  quite  different  in  form  from  that 
shown  in  most  text-books.  Professor  Bonder  has 
spoken  of  the  space  between  the  roof  of  the  mouth  and 
the  tongue  as  acting  somewhat  on  the  same  principle  as 
the  vacuum  chamber  in  an  upper  artificial  denture,  i.  e., 
when  the  air  is  exhausted  by  the  action  of  the  tongue  a 
partial  vacuum  is  created  when  the  tongue  is  relaxed, 
by  the  action  of  which  the  weight  of  the  lower  jaw,  with 
the  tongue,  is  overcome  to  a  certain  extent  "  (Cryer) 
(Fig.  14). 

The  muscles  of  the  tongue  are  divided  into  two 
groups,  the  extrinsic  group  and  the  intrinsic  group. 

The  extrinsic  muscles  of  the  tongue  are :  The  hyoglossus, 
the  geniohyoglossus,  and  the  styloglossus.  The  palato- 
glossus is  also  attached  to  the  tongue,  but  vvill  be  des- 
cribed with  the  muscles  of  the  soft  palate. 

The  hyoglossus  muscle  arises  from  the  greater  and  lesser 
cornua  of  the  hyoid  bone,  and  is  inserted  into  the  pos- 
terior and  lateral  portions  of  the  tongue.  It  is  supplied 
by  the  hypoglossal  nerve.  Its  action  is  to  aid  in  depress- 
ing the  tongue. 

The  geniohyoglossus  is  a  fan-shaped  muscle  arising 
from  the  superior  genial  tubercle  of  the  mandible.  It 
spreads  out  and  passes  backward,  its  upper  fibers  being 


52 


APPLIED  ANATOMY 


MUSCLES  AND   FASCIA  53 

inserted  into  the  under  surface  of  the  body  of  the  tongue, 
and  its  lower  fibers  running  to  the  hyoid  bone.  This 
muscle  is  suppHed  by  the  hypoglossal  nerve.  Its  action 
is  to  draw  forward  and  protrude  the  tongue. 

The  styloglossus  muscle  arises  near  the  apex  of  the  sty- 
loid process  and  passes  forward,  downward,  and  inward 
to  the  posterior  part  of  the  tongue,  where  it  divides  into 
a  longitudinal  portion,  passing  forward,  and  an  oblique 
portion,  passing  downward.  Its  nerve-supply  is  derived 
from  the  hypoglossal.  The  styloglossus  assists  in  re- 
tracting and  elevating  the  tongue. 

The  intrinsic  muscle  of  the  tongue  is  the  lingualis. 

The  principal  bulk  of  the  Hngualis  is  a  longitudinal 
set  of  muscular  fibers,  arising  at  the  base  and  extending 
between  the  hyoglossus  and  the  geniohyoglossus  muscles 
to  the  apex  of  the  tongue.  It  mingles  with  the  fibers 
of  the  extrinsic  muscles.  The  linguaHs  is  suppHed  by 
the  hypoglossal  nerve.  Its  different  portions  have  vari- 
ous complex  movements. 

Muscles  of  the  Pharynx  and  Soft  Palate 

This  group  includes  the  superior,  middle,  and  inferior 
constrictors  of  the  pharynx,  the  stylopharyngeus,  the 
palatopharyngeus,  palatoglossus,  tensor  palati,  levator 
palati.  and  azygos  uvulae. 

The  constrictor  muscles  of  the  pharynx  are  three  prac- 
tically continuous  sheets  of  muscle  placed  one  below  the 
other.  They  arise  from  various  bony  and  cartilaginous 
points  in  front  of  the  pharynx,  and  are  inserted  poste- 
riorly into  a  median  raph^.  The  superior  and  middle 
constrictors  receive  their  nerve  supply  from  the  pharyn- 
geal plexus,  and  the  inferior  constrictor  is  supplied  by 


54  APPLIED  ANATOMY 

the  pharyngeal  plexus  and  the  external  laryngeal  nerve. 
These  muscles,  by  contracting  one  after  the  other  from 
above  downward,  are  the  principal  agents  in  the  function 
of  deglutition. 

The  stylo pharyngeus  muscle  arises  from  the  styloid 
process  near  its  base,  passes  downward  and  inward 
between  the  superior  and  middle  constrictors  of  the 
pharynx,  and  is  inserted  into  the  lateral  walls  of  the 
pharynx  and  the  posterior  border  of  the  thyroid  cartilage. 
It  is  supphed  by  the  glossopharyngeal  nerve  and  assists 
in  elevating  the  pharynx. 

The  palato pharyngeus  muscle  arises  from  the  posterior 
portion  of  the  soft  palate,  and  is  inserted  into  the  lower 
part  of  the  pharynx  and  the  upper  and  posterior  border 
of  the  thyroid  cartilage.  This  muscle  and  its  fellow  of 
the  opposite  side  form  the  posterior  pillars  of  the  fauces. 
The  nerve-supply  of  this  muscle  is  derived  from  the 
sphenopalatine  or  Meckel's  ganglion.  Its  action  is  to 
elevate  the  pharynx  in  deglutition,  to  open  the  Eustach- 
ian tube,  and  to  keep  the  soft  palate  in  position  during 
respiration. 

The  palatoglossus  arises  from  the  under  surface  of  the 
soft  palate  near  the  base  of  the  uvula,  and  is  inserted 
into  the  side  and  base  of  the  tongue.  This  muscle  and 
its  fellow  of  the  opposite  side  form  the  anterior  pillars 
of  the  fauces.  Its  nerve-supply  is  from  the  facial. 
The  action  of  this  muscle  is  to  depress  and  draw  slightly 
forward  the  palate  and  elevate  and  draw  back  the 
tongue. 

The  tensor  palati  muscle  arises  from  the  scaphoid 
fossa  at  the  root  of  the  pterygoid  plates,  the  spinous 
process  of  the  sphenoid  bone,  and  the  side  of  the  Eus- 


MUSCLES  AND   FASCI/E  55 

tachian  tube.  Its  tendon  passes  around  the  hamular 
process  of  the  sphenoid  bone  and  is  inserted  into  the 
aponeurosis  of  the  soft  palate  and  transverse  ridge  on 
the  lower  surface  of  the  palate  bone.  The  nerve-supply 
is  derived  from  the  otic  ganglion.  The  muscle  renders 
the  palate  tense  and  opens  the  Eustachian  tube. 

The  levator  palati  muscle  arises  from  the  lo\yer  surface 
of  the  petrous  portion  of  the  temporal  bone,  and  is 
inserted  into  the  soft  palate.  Its  nerve-supply  is  from 
the  sphenopalatine  ganglion.  The  action  of  the  muscle 
is  to  raise  the  soft  palate  and  to  narrow  the  orifice  of 
the  Eustachian  tube. 

The  azygos  uvula:  arises  from  the  posterior  spine  of 
the  palate  bone,  and  is  inserted  into  the  uvula.  It  is 
supplied  by  the  facial  nerve.  The  action  of  the  muscle 
is  to  contract  the  uvula. 

Muscles  of  Mastication 

The  following  are  the  muscles  of  mastication.  Tem- 
poral, masseter,  internal  pterygoid,  external  pterygoid. 
The  accessory  muscles  are  buccinator,  platysma  myoides, 
digastric,  mylohyoid,  geniohyoid. 

The  temporal  muscle  arises  from  the  temporal  fossa 
and  from  the  temporal  fascia.  It  is  inserted  into  the 
coronoid  process  of  the  mandible.  It  is  supphed  by 
a  branch  of  the  mandibular  division  of  the  trifacial 
nerve.  The  function  of  the  temporal  muscle  is  to  pull 
the  lower  jaw  upward  and  backward. 

The  masseter  muscle  consists  of  a  superficial  portion 
and  a  deep  portion  (Fig.  15).  The  superficial  portion 
arises  from  the  anterior  two-thirds  of  the  lower  border  of 
the  zygoma.     It  is  inserted  into  the  lower  part   of  the 


56 


APPLIED  ANATOMY 


outer  side  of  the  ramus  of  the  mandible.  The  deep 
portion  arises  from  the  posterior  third  of  the  lower 
border  of  the  zygoma,  and  from  its  entire  inner  surface. 
It  is  inserted  into  the  upper  portion  of  the  outer  side 
of  the  ramus  of  the  lower  jaw.  The  nerve-supply  of 
the  masseter  muscle  is  derived  from  the  mandibular 
division  of  the  trifacial.     The  superficial  portion  of  the 


^11^  a. 


Fig.  15. — Masseter  muscle  (Campbell). 


masseter  draws  the  lower  jaw  forward  and  upward. 
The  deep  portion  draws  it  backward  and  upward. 

The  internal  pterygoid  vcmscle  (Fig.  16)  arises  from  the 
inner  surface  of  the  external  pterygoid  plate  and  ptery- 
goid fossa  of  the  sphenoid  bone,  and  from  the  tuberosities 
of  the  palate  and  maxillary  bones.  It  is  inserted  into 
the  inner  side  of  the  ramus  and  angle  of  the  mandible. 


MUSCLES  AND   FASCIM  57 

The  nerve-supply  of  the  internal  pterygoid  is  derived 
from  the  mandibular  division  of  the  trifacial.  This 
muscle  elevates  the  lower  jaw. 

The  external  pterygoid  muscle  arises  by  two  heads, 
one  from  the  outer  surface  of  the  external  pterygoid 
plate  of  the  sphenoid  and  the  other  from  the  zygomatic 
surface   of   the   greater   wing   of   the   sphenoid.     It   is 


n 

s  *^ 

M 

1      "> 

mm 

ll^ 

^^^^B  '^^V/'jP 

P--                A 

Hl^ 

P^^^ 

^^■BpT^^^B^' 

\ 

:^J^'' 

lig.  16.— Internal  i)terygoid  muscle  (Campbell). 

inserted  into  the  anterior  part  of  the  neck  of  the 
condyle  of  the  mandible,  and  into  the  interarticular 
fibrocartilage  of  the  temporomandibular  joint.  The 
nerve-supply  to  this  muscle  is  derived  from  the  mandib- 
ular division  of  the  trifacial.  The  two  external  ptery- 
goid muscles  acting  together  draw  the  lower  jaw  forward. 
When  the  mandible  is  depressed  to  a  certain  extent, 


58  APPLIED  ANATOMY 

it  is  further  depressed  by  the  action  of  these  muscles. 
Acting  separately,  the  external  pterygoids  draw  the 
mandible  to  one  side  or  the  other.  The  slip  to  the  inter- 
articular  fibrocartilage  pulls  the  latter  forward  on  to  the 
eminentia  articularis  when  the  condyle  moves  forward. 

The  huccinator  muscle  arises  from  the  posterior  part 
of  the  alveolar  processes  of  the  maxilla  and  mandible, 
and  from  the  pterygomaxillary  ligament.  It  is  inserted 
into  the  orbicularis  oris  muscle,  and  blends  with  the 
other  muscles  of  expression  of  the  face.  It  is  supplied 
by  a  branch  of  the  mandibular  division  of  the  trifacial 
nerve,  and  also  by  the  facial  nerve.  This  muscle  com- 
presses the  cheek,  and  assists  in  keeping  the  food  between 
the  teeth. 

The  platysma  myoides  is  a  broad,  thin  sheet  of  muscle 
arising  from  the  clavicle,  the  acromion,  and  the  super- 
ficial fascia  of  the  neck.  It  runs  upward  within  the 
meshes  of  the  superficial  fascia,  and  is  inserted  into  the 
lower  border  of  the  mandible,  where  it  blends  with  the 
superficial  muscles  of  the  face.  It  is  supplied  by  the 
facial  and  superficial  cervical  nerves.  The  platysma 
helps  to  depress  the  lower  jaw  and  open  the  mouth. 

The  digastric  is  a  bi-bellied  muscle,  which  arises  from 
the  digastric  groove  on  the  mastoid  process  of  the 
temporal  bone,  and  from  the  lower  border  of  the  mandible 
near  the  symphysis.  The  two  heads  converge  into  a 
tendon,  which  is  attached  to  the  hyoid  bone  by  a  fibrous 
loop  from  the  stylohyoid  muscle.  The  posterior  belly 
of  the  digastric  is  supplied  by  the  facial  nerve,  and  the 
anterior  belly  by  the  mylohyoid  branch  of  the  trifacial. 
The  digastric  muscle  aids  in  depressing  the  lower  jaw. 

The  mylohyoid  muscle,  with  its  fellow  of  the  opposite 


MUSCLES  AND  FASCIA  59 

side,  forms  the  muscular  floor  of  the  mouth.  It  arises 
from  the  mylohyoid  ridge  on  the  inner  surface  of  the 
body  of  the  mandible,  passes  downward  and  inward 
to  be  inserted  into  the  body  of  the  hyoid  bone,  and  into 
a  median  raphe  in  the  floor  of  the  mouth.  It  is  supplied 
by  the  mylohyoid  nerve,  a  branch  of  the  mandibular 
division  of  the  trifacial.  This  muscle  slightly  assists 
in  depressing  the  mandible. 

The  geniohyoid  muscle  arises  from  the  inferior  genial 
tubercle  of  the  mandible,  and  is  inserted  into  the  anterior 
portion  of  the  hyoid  bone.  Its  nerve-supply  is  from 
the  hypoglossal.     It  aids  in  depressing  the  lower  jaw. 

Muscles  of  Expression  About  the  Mouth 

The  muscles  of  expression  of  the  face  (Fig.  17)  differ 
from  other  voluntary  muscle  in  that  none  of  them 
have  bony  insertions,  and  some  of  them  have  no  bony 
origin.  The  oral  group  consists  of  the  orbicularis  oris 
and  those  muscles  that  are  inserted  into  it. 

The  orbicularis  oris  forms  the  sphincter  of  the  mouth. 
It  is  elliptic,  and  its  fibers  interlace  with  those  of  the 
other  muscles  of  expression.  The  remaining  muscles 
are  inserted  into  the  orbicularis  oris,  and  are  as  follows, 
beginning  at  the  median  line  above: 

Levator  labii  superioris  alcequc  nasi,  arises  from  the 
upper  and  outer  part  of  the  nasal  process  of  the  maxilla. 

Levator  labii  superioris,  arises  from  the  maxilla  im- 
mediately below  the  orbit. 

The  depressor  labii  superioris  arises  from  the  incisor 
fossa  of  the  maxilla. 

The  zygomaticus  minor  arises  from  the  lower  surface 
of  the  malar  bone. 


6o 


APPLIED  ANATOMY 


The  zygomaticus  major  is  just  behind  the  zygomaticus 
minor,  arising  from  the  lower  edge  of  the  malar  bone, 
near  the  zygomatic  suture. 

The  levator  anguli  oris  arises  from  the  canine  fossa, 
immediately  below  the  infra-orbital  foramen. 


Fig.  17. — Muscles  of  the  right  side  of  the  head  and  neck  (American  Illus- 
Iraled  Medical  Dictionary):  i.  Frontalis;  2,  superior  auricular;  3,  posterior  auric- 
ular; 4,  orbicularis  palpebrarum;  5,  pyramidalis  nasi;  6,  compressor  naris;  7, 
levator  labii  superioris  alaeque  nasi;  8,  levator  labii  superioris;  g,  zygomaticus 
major;  10,  orbicularis  oris;  11,  depressor  labii  inferioris;  12,  depressor  anguli 
oris;  13,  anterior  belly  of  digastric;  14,  mylohyoid;  15,  hyoglossus;  16,  stylo- 
hyoid; 17,  posterior  belly  of  digastric;  18,  the  masseter;  19,  sternohyoid;  20, 
anterior  belly  of  omohyoid;  21,  thyrohyoid;  22,  23,  lower  and  middle  constric- 
tors of  pharynx;  24,  sternomastoid ;  25,  26,  splenius;  27,  levator  scapula;;  28, 
anterior  scalenus;  29.  posterior  belly  of  omohyoid;  30,  middle  and  posterior 
scalenus;  31,  trapezius. 


The  risorius  muscle  arises  from  the  deep  fascia  cover- 
ing the  masseter  muscle.     It  is  not  always  present. 

The  depressor  anguli  oris  {triangularis  menti)  arises 
from  the  external  oblique  line  of  the  mandible. 

The  depressor  labii  inferioris  {quadratus  menti)  arises 


MUSCLES  AND  FASCIA  6l 

from  the  mandible  along  the  line  extending  from  the 
s}'mphysis  to  the  mental  foramen. 

The  levator  lahii  inferioris  arises  from  the  upper  por- 
tion of  the  incisor  fossa  of  the  mandible. 

The  action  of  the  foregoing  muscles  is  indicated  by 
their  names. 

The  nerve-supply  is  through  branches  of  the  facial. 

Muscles  Attached  to  the  Mandible  (Fig.  2) 
To  the  iimer  surface  of  the  body: 

Gcniohyoglossiis,  to  the  superior  genial  tubercle. 

Geniohyoid,  to  the  inferior  genial  tubercle. 

Digastric,  to  the  digastric  fossa. 

Mylohyoid,  to  the  mylohyoid  ridge  or  internal  oblique 
line. 

Superior  constrictor  of  pharynx,  just  behind  the  third 
molar  tooth. 

Outer  surface  of  the  body  of  the  mandible : 

Platysma  myoides,  depressor  anguli  oris,  and  depressor 
labii  inferioris,  to  external  oblique  line. 

Levator  lahii  inferioris,  to  incisor  fossa.   ■ 

Levator  menti,  to  symphysis. 

Buccinator ,  to  outer  surface  of  alveolar  process  of 
molar  teeth. 

Inner  surface  of  ramus: 

Internal  pterygoid. 

Outer  surface  of  ramus: 

Masseter. 

Coronoid  process:  Temporal. 

Neck  of  condyle:  External  pterygoid. 


62  applied  anatomy 

Review  Questions 

Describe  the  cervical  fasciae. 

Give  the  boundaries  and  coverings  of  the  surgical  square  of  the  neck. 

Name  the  triangles  of  the  neck,  giving  their  boundaries  and  the  most 
important  structures  found  in  each. 

Which  triangle  is  the  most  important  to  the  oral  surgeon,  and  why? 

Give  the  position  of  the  tongue,  and  name  its_  extrinsic  and  intrinsic 
muscles. 

Name  the  muscles  of  the  soft  palate,  giving  origin,  insertion,  and 
nerve-supply. 

Name  the  muscles  of  mastication. 

Name  the  accessory  muscles  of  mastication. 

Give  the  origin,  insertion,  nerve-supply,  and  function  of  the  temporal, 
masseter,  internal  pterygoid,  and  external  pterygoid  muscles. 

Name  the  muscles  inserted  into  the  sphincter  of  the  mouth.  Give 
their  function  and  nerve-supply. 

Name  and  locate  the  muscles  attached  to  the  mandible. 


CHAPTER  IV 

BLOOD-VESSELS 

The  blood-supply  of  the  head  (Fig.  i8)  is  carried 
mainly  by  the  common  carotid  and  vertebral  arteries. 

The  right  common  carotid  artery  is  a  branch  of  the 
innominate  artery.  The  left  common  carotid  comes 
directly  from  the  arch  of  the  aorta.  Apart  from  this, 
the  arteries  of  the  two  sides  are  similar. 

The  surgical  line  of  the  common  carotid  artery  ex- 
tends from  the  sternoclavicular  articulation  to  a  point 
midway  between  the  angle  of  the  mandible  and  the 
mastoid  process  of  the  temporal  bone.  While  this  is 
the  direction  of  the  artery  in  the  neck,  its  upper  termi- 
nation is  at  the  level  of  the  upper  edge  of  the  thyroid 
cartilage.  The  common  carotid  artery  lies  in  the  carotid 
sheath,  a  process  of  the  cervical  fascia  (p.  48)  which 
also  incloses  the  internal  jugular  vein  and  the  pneumo- 
gastric  nerve.  The  vein  lies  external  to  the  artery,  while 
the  nerve  is  between  and  behind  the  two.  The  descen- 
dens  h>poglossi  nerve,  a  branch  of  the  hypoglossal, 
passes  down  the  neck  on  the  front  of  the  carotid  sheath. 
The  structures  within  the  carotid  sheath  lie  just  beneath 
the  inner  edge  of  the  sternocleidomastoid  muscle. 

At  the  level  of  the  upper  edge  of  the  thyroid  cartilage, 
in  the  superior  carotid  triangle,  the  common  carotid 
bifurcates  into  the  interna!  and  external  carotid  arteries. 

The  internal  carotid  artery  (Fig.  19)  passes  upward 

63 


64 


APPLIED   ANATOMY 


to  the  carotid  canal  in  the  petrous  portion  of  the  tem- 
poral bone.  It  is  divided  into  four  portions — cervical, 
petrous,  cavernous,  and  intracranial. 


Fig.  1 8. — The  chief  arteries  of  the  neck:  A,  Common  carotid;  B,  external  caro- 
tid; C,  internal  carotid;   D,  vertebral  (Deaver,  modified). 

The  cervical  portion  is  at  first  more  superficial  than, 
and  to  the  outer  side  of,  the  external  carotid  artery.  It 
then  passes  more  deeply,  in  relation  with  the  superior 


BL  OOD-  VESSELS  65 

constrictor  of  the  pharynx,  which  separates  it  from  the 
tonsil,  and  the  transverse  processes  of  the  three  upper 
cervical  vertebrae.  The  artery  is  inclosed  in  a  sheath 
in  company  with  the  internal  jugular  vein  and  the  pneu- 
mogastric  nerve. 


Fig.  ig.— The  carotid  region  and  the  chief  structures  (Campbell).  Note 
the  relation  of  the  internal  jugular  vein,  the  common  carotid  artery,  and  the 
pneumogastric  nerve. 

The  petrous  portion  of  the  internal  carotid  is  inclosed 
in  the  carotid  canal  in  the  petrous  portion  of  the  temporal 
bone. 

The  cavernous  portion  is  inclosed  by  the  cavernous 
sinus,  and  begins  just  above  the  middle  lacerated  fora- 
men within  the  brain  case. 
5 


66 


APPLIED  ANATOMY 


The  intracranial  portion  begins  at  a  point  where  the 
artery  passes  through  the  upper  wall  of  the  cavernous 
sinus,  and  gives  off  the  terminal  branches. 

The  cervical  portion  of  the  internal  carotid  artery 
seldom  gives  off  any  branches. 

The  petrous  portion  gives  off  the  tympanic  branch. 

The  branches  of  the  cavernous  portion  are :  Meningeal, 
pituitary,  and  cavernous. 

The  branches  of  the  intracranial  portion  are :  Ophthal- 
mic, anterior  cerebral,  middle  cerebral. 

The  ophthalmic  artery  is  the  largest  branch  of  the 
internal  carotid.  It  passes  through  the  optic  foramen, 
and  gives  off  the  lacrimal,  supra-orbital,  central  retinal, 
ciliary,  posterior  and  anterior  ethmoid,  muscular, 
palpebral,  frontal,  and  external  nasal  branches. 

The  anterior  and  middle  cerebral  arteries  assist  in  the 
formation  of  the  circle  of  Willis. 


BRANCHES    OF   INTERNAL    CAROTID  ARTERY. 


Cervical  portion. 

None. 

Petrous  portion. 

Tympanic. 

r  Meningeal. 

Cavernous  portion.     ■ 

Pituitary. 
'■  Cavernous. 

' 

'  Lacrimal. 
Supra-orbital. 

Internal 
carotid. 

Intracranial  portion.  ^ 

L 

Ophthalmic.  ' 

Anterior  cereb 
^  Middle  cerebr 

Central  retinal. 

Ciliary. 

Posterior  ethmoid 

Anterior  ethmoid. 

Muscular. 

Palpebral. 

Frontal. 

External  nasal, 
ral. 
al. 

BL  O OD-  VESSELS  6y 

The  External  Carotid  Artery. — The  external  carotid 
artery  (Fig.  i8)  is  given  off  from  the  common  carotid 
in  the  superior  carotid  triangle.  It  passes  up  the  neck 
to  a  point  opposite  the  neck  of  the  condyle  of  the  man- 
dible, where  it  gives  off  its  terminal  branches  in  the  sub- 
stance of  the  parotid  gland. 

]Most  of  the  branches  of  the  external  carotid  artery 
are  given  oft  in  the  superior  carotid  triangle. 

The  branches  are: 

Ascending  pharyngeal,  to  the  upper  part  of  the  phar- 
ynx. 

Superior  thyroid,  to  the  thyroid  gland,  larynx,  and 
various  muscles. 

Lingual,  to  the  tongue. 

Facial. — This  branch  runs  upward  and  inward  to 
the  angle  of  the  lower  jaw,  passes  over  the  facial  notch 
in  the  lower  border  of  the  mandible  near  the  angle, 
thence  to  the  angle  of  the  mouth,  the  ala  of  the  nose,  and 
the  inner  canthus  of  the  eye. 

The  occipital  artery  passes  backward  and  upward  and 
supplies  the  structures  in  the  region  of  the  occiput. 

The  posterior  auricular  artery  passes  upward  and 
backward  to  supply  the  region  behind  the  ear. 

The  superficial  temporal  artery  is  one  of  the  terminal 
branches  of  the  external  carotid,  and  is  given  off  in  the 
substance  of  the  parotid  gland.  It  passes  upward  in 
front  of  the  ear,  accompanied  by  the  auriculotemporal 
nerve,  and  is  distributed  to  the  temporal  region  of  the 
scalp. 

The  internal  maxillary  artery  (Fig.  i8)  is  the  other 
terminal  branch  of  the  external  carotid,  and  is  given 
off  in  the  substance  of  the  parotid  gland.     It  winds 


68  APPLIED  ANATOMY 

around  the  inner  side  of  the  neck  of  the  condyle  of  the 
mandible,  between  it  and  the  internal  lateral  Hgament, 
passes  between  the  two  heads  of  the  external  pterygoid 
muscle,  and  enters  the  sphenomaxillary  fossa,  where 
it  breaks  up  into  its  terminal  branches.  The  artery 
may  be  divided  into  three  portions:  (i)  The  maxillary 
division,  extending  from  the  external  carotid  to  the 
internal  lateral  Hgament.  (2)  Pterygoid  division,  between 
the  two  heads  of  the  external  pterygoid  muscle.  (3) 
Sphenomaxillary  division,  in  the  sphenomaxillary  fossa. 

The  branches  of  the  lingual  artery  are:  hyoid,  dorsaHs 
hnguas,  sublingual,  and  ranine. 

The  branches  of  the  facial  artery  are :  id)  On  the  neck : 
Ascending  palatine,  tonsillar,  submaxillary,  submental. 
(6)  On  the  face:  Inferior  labial,  inferior  coronary,  supe- 
rior coronary,  lateralis  nasi,  angular. 

The  branches  of  the  internal  maxillary  artery  are  as 
follows:  {a)  Maxillary  portion:  Tympanic,  middle 
meningeal,  small  meningeal,  and  inferior  dental.  (6) 
Pterygoid  portion:  Deep  temporal,  pterygoid,  masseteric, 
and  buccal.  (c)  Sphenomaxillary  portion:  Alveolar 
to  the  upper  teeth,  infra-orbital,  descending  palatine, 
vidian,  pterygopalatine,  and  nasopalatine. 

The  vertebral  arteries  are  given  off  from  the  subclavian 
arteries,  and  pass  upward  one  on  either  side  of  the  neck, 
through  the  foramina  in  the  transverse  processes  of  the 
cervical  vertebrae,  entering  the  skull  through  the  foramen 
magnum.  The  arteries  of  the  two  sides  join  at  the 
posterior  inferior  extremity  of  the  pons  Varolii  to  form 
the  basilar. 

The  basilar  artery  at  the  anterior  extremity  of  the 
pons  divides  into  the  posterior  cerebral  arteries.     These 


BLOOD-VESSELS 


69 


anastomose  with  the  anterior  cerebral  branches  of  the 
internal  carotid  arteries  through  the  posterior  com- 
municating arteries.     The  circle  of  Willis  is  completed 


Fig.  20. — Diagram  of  the  circle  of  Willis:  A,  Basilar  artery;  B,  posterior 
cerebral;  C,  posterior  communicating;  D,  internal  carotid;  F,  anterior  cerebral; 
G,  anterior  communicating  (Campbell). 

in  front  by  the  anterior  communicating  artery,  which 
joins  the  two  anterior  cerebral  arteries  (Fig.  20). 


Veins  of  the  Head 

The  veins  of  the  head  may  be  divided  into  external 
and  intracranial. 

Practically  all  the  venous  blood  from  the  head  is 
conveyed  by  the  internal  and  external  jugular  veins. 

The  following  table  gives  the  principal  veins  of  the 
head  and  their  tributaries: 


70  APPLIED  ANATOMY 

EXTERNAL    VEINS. 

Temporal.  It-  -n 

T  ,         •„         r  Temporomaxillary.  1  ^  ,  .       ,       r-  i    ,     • 

Internal  maxillary.  J  _         .  .     ,       <  External  luffular.  bubclavian. 

Posterior  auricular.  > 

Facial.  ~) 

Anterior  division   of  )-  Common  facial. 

temporomaxillary.  J  Lingual. 

Pharyngeal. 

Superior  thyroid. 

Middle  thyroid. 

Occipital. 


Internal  jugular. 


The  internal  jugular  vein  is  formed  by  the  union  of 
the  lateral  and  inferior  petrosal  sinuses  at  the  posterior 
lacerated  or  jugular  foramen.  These  sinuses  and  their 
tributaries  convey  venous  blood  from  the  structures 
of  the  interior  of  the  skull,  including  the  brain  and  its 
membranes,  orbit,  etc. 

Venous  blood  is  conveyed  from  the  upper  teeth  by  the 
alveolar  vein  into  the  internal  maxillary  vein;  that  from 
the  lower  teeth  is  carried  by  the  inferior  dental  vein  to 
the  internal  maxillary  vein. 

The  course  of  blood  from  the  heart  to  the  right  upper 
teeth  and  back  again  to  the  heart  is  as  follows:  Aorta, 
innominate,  right  common  carotid,  external  carotid, 
internal  maxillary,  and  alveolar  arteries;  alveolar, 
internal  maxillary,  temporomaxillary,  external  jugular, 
subclavian,  and  innominate  veins,  superior  vena  cava, 
to  heart.  In  supplying  the  teeth  of  the  left  side  the 
course  of  blood  is  the  same,  except  that  it  passes  directly 
from  the  aorta  into  the  left  common  carotid  artery, 
instead  of  first  traversing  the  innominate.  The  lower 
teeth  receive  blood  from  the  inferior  dental  instead  of 
the  alveolar  branch  of  the  internal  maxillary. 


BL  O OD-  VESSELS  7 1 

By  anastomosis  is  meant  the  free  communication  of 
blood-vessels.  Practically  all  blood-vessels  anastomose 
with  adjacent  trunks.  The  best  example  of  an  anasto- 
mosis is  the  circle  of  Willis  at  the  base  of  the  brain 
(p.  69),  where  branches  of  the  internal  carotid  and 
vertebral  arteries  of  the  two  sides  communicate  to  form 
a  complete  circle. 

A  collateral  circulation  is  an  accessory  source  of  blood- 
supply  to  a  part  by  anastomosis  of  vessels,  whereby 
nutrition  is  maintained  after  the  main  source  of  blood- 
supply  is  cut  off.  A  good  example  of  this  in  the  neck  is 
seen  in  the  anastomosis  of  the  princeps  cervicis  branch 
of  the  occipital  with  the  profunda  cervicis  branch  of 
the  superior  intercostal,  which  comes  from  the  subclavian, 
so  that  if  the  blood-supply  to  the  occipital  region  through 
the  external  carotid  artery  be  cut  off  from  any  cause, 
blood  would  still  be  carried  to  the  part  by  the  branch  of 
the  subclavian. 

Review  Questions 

Give  the  surgical  line  of  the  common  carotid  artery. 

Name  and  give  the  relations  of  the  structures  within  the  carotid 
sheath. 

Give  the  point  of  bifurcation  of  the  common  carotid  artery  and  its 
branches. 

Give  the  course  and  branches  of  the  internal  carotid  artery. 

Give  the  course  and  branches  of  the  external  carotid  artery. 

Give  the  course  and  branches  of  the  facial  artery. 

Give  the  course  and  branches  of  the  internal  maxillary  arlcry. 

Describe  the  circle  of  Willis. 

Give  a  general  outline  of  the  veins  of  the  face  and  neck. 

What  is  meant  by  anastomosis  of  blood-vessels. 

What  is  meant  by  collateral  circulation?     Give  examples. 


CHAPTER  V 

LYMPHATICS 

The  lymphatic  glands  of  the  face  are  as  follows :  (a) 
Parotid,  of  which  there  are  two  groups,  one  placed  on  the 
surface  of  the  parotid  salivary  gland,  and  the  other 
more  deeply  in  the  substance  of  the  gland,  (b)  Zygo- 
matic, beneath  the  zygoma,  (c)  Buccal,  on  the  surface 
of  the  buccinator  muscle,  (d)  Internal  maxillary,  on 
the  inner  side  of  the  ramus  of  the  mandible. 

The  lymphatic  glands  of  the  neck  are  superficial  and 
deep.  The  superficial  groups  are:  (a)  Submaxillary, 
beneath  the  body  of  the  mandible,  in  the  submaxillary 
triangle,  (b)  Suprahyoid,  in  the  median  line  of  the 
neck,  (c)  Cervical,  along  the  course  of  the  external 
jugular  vein. 

The  deep  cervical  glands  are  found  along  the  course 
of  the  internal  jugular  vein,  and  are  divided  into  an 
upper  and  a  lower  group.  Practically  all  the  lymphatics 
of  the  head  drain  into  the  deep  cervical  glands,  which 
communicate  below  with  the  mediastinal  glands. 

The  following  table  gives  the  various  structures  of 
the  face  and  neck,  and  the  lymphatic  glands  connected 
with  them  (Treves) : 

Skin  of  face  and  neck Submaxillary,  parotid,  and  superficial 

cervical  glands. 

External  ear Superficial  cervical  glands. 

Lower  lip Submaxillary  and  suprahyoid  glands. 

72 


L  YMPHA  TICS  73 

Buccal  cavity Submaxillary  and  upper  set  of  deep  cer- 
vical glands. 

Lower  jaw Submaxillary  glands. 

Anterior  portion  of  tongue Suprahyoid  and  submaxillary  glands. 

Posterior  portion  of  tongue Upper  set  of  deep  cervical  glands. 

Tonsils  and  palate Upper  set  of  deep  cervdcal  glands. 

Upper  part  of  pharynx Parotid  and  retropharyngeal  glands. 

Lower  part  of  pharynx Upper  set  of  deep  cervical  glands. 

Lan^-nx,  orbit,  roof  of  mouth  .  .  .  .Upper  set  of  deep  cervical  glands. 

Nasal  fossae Retropharyngeal  and  upper  set  of  deep 

cervical  glands. 


CHAPTER  VI 

THE  CRANIAL  NERVES 

The  cranial  nerves,  with  their  foramina  of  exit  from 
the  brain-case,  principal  distribution,  and  function,  are 
as  follows: 


Name. 

Foramen. 

DlSTRIBUTION. 

Function. 

First:  olfactory. 

Olfactory^ 

Nose. 

Smell. 

Second:  optic. 

Optic.. 

Eye. 

Sight. 

Third:      oculo- 

Sphenoid 

fis-" 

Orbit. 

Motor  to  mus- 

motor. 

sure. 

cles  of  eyeball. 

Fourth:    troch- 

Sphenoid 

fis- 

Superior        ob- 

Motor. 

lear. 

sure. 

lique    muscle 
of  eyeball. 

Fifth:  trifacial. 

[a)  Sphenoii 
sure. 

dfis- 

Ophthalmic. 

Sensory. 

(b)  Rotundi 

im. 

Maxillary. 

Sensory. 

(c)  Ovale. 

Mandibular. 

Sensory.      Mo- 
tor   to    mus- 
cles of  masti- 
cation. 

Sixth:  abducens. 

Sphenoid 
sure. 

fis- 

External  rectus 
muscle. 

Motor. 

Seventh:  facial. 

Stylomastoid.  . 

Facial  muscles. 

Motor. 

Eighth:     audit- 

Internal   audit-  ■ 

Internal   ear. 

Audition      and 

ory. 

ory  meatus. 

equilibration. 

Ninth:     glosso- 

Jugular. 

Tongue,     phar- 

Sensory. 

pharyngeal. 

ynx,     middle 
ear.       Stylo- 
pharyngeus. 

Taste.     Motor. 

Tenth :  pneumo- 

Jugular. 

Alimentary,  res- 

Sensory       and 

gastric. 

piratory,  and 

circulatory 

systems. 

motor. 

THE   CRANIAL   NERVES 


n 


N.\iIE. 

Foramen. 

Distribution. 

Function. 

Eleventh:  spinal 

Jugular. 

Stemomast  o  i  d 

IMotor. 

accessor>-. 

and  trapezius 
muscles. 

Twelfth:    hj-po- 

Anterior  condy- 

Tongue        and 

Motor. 

glossal. 

loid. 

muscles  of 
hyoid  bone. 

The  Fifth  Nerve 
The  fifth    or    trifacial  nerve  (Fig.   21)  is  the  great 
sensory  nerve  of  the  face  and  head.     It  also  suppUes 
motor  fibers  to  the  muscles  of  mastication.     The  deep 


Fig.  21.— The  distribution  of  the  three  divisions  of  the  fifth  nerve  fLeidy). 

origin  of  the  trifacial  nerve  is  from  a  sensory  nucleus 
and  a  motor  nucleus  in  the  floor  of  the  fourth  ventricle. 
The  superficial  origin  is  from  the  side  of  the  pons 
Varolii,  where  the  nerve  emerges  as  an  anterior  motor 
and  a  posterior  sensory  root.     The  sensory  root  term  in- 


76  APPLIED  ANATOMY 

ates  in  the  Gasserian  ganglion,  situated  at  the  apex  of 
the  petrous  portion  of  the  temporal  bone,  within  the 
brain-case.  The  motor  root  passes  out  through  the 
foramen  ovale  and  joins  the  sensory  portion  of  the 
mandibular  division  immediately  outside  this  foramen. 

The  Gasserian  or  semilunar  ganglion  is  a  crescent- 
shaped  structure,  with  its  convexity  directed  forward, 
situated  in  a  depression  at  the  apex  of  the  petrous 
portion  of  the  temporal  bone.  The  ganglion  is  joined 
posteriorly  by  the  sensory  root  of  the  trifacial  nerve. 
The  motor  root  of  this  nerve  does  not  enter  the  ganglion, 
but  passes  around  it  and  joins  the  inferior  division  from 
the  ganglion  outside  the  foramen  ovale  to  form  the 
mandibular  nerve. 

The  branches  of  the  Gasserian  ganglion,  three  in 
number,  are  given  off  from  its  anterior  portion,  and  are 
as  follows: 

First,  or  ophthalmic  division. 

Second,  or  maxillary  division. 

Third  division,  which  unites  with  the  motor  root  to 
form  the  mandibular  nerve. 

The  ophthalmic  division  passes  forward  along  the  outer 
wall  of  the  cavernous  sinus,  passes  through  the  sphenoid 
fissure,  and  breaks  up  into  three  branches,  frontal,  lacri- 
mal, and  nasal. 

The  frontal  nerve  passes  forward  in  the  orbit,  and 
divides  into  two  branches,  the  supra-orbital  and  the 
supratrochlear.  The  supra-orbital  nerve  passes  through 
the  supra-orbital  foramen,  and  supplies  the  skin  of  the 
forehead.  The  supratrochlear  nerve  leaves  the  orbit 
near  its  inner  angle  and  supplies  the  skin  of  that  region. 

The  lacrimal  nerve  passes  forward  in  the  orbit,  and 


THE    CRANIAL   NERVES  Tj 

breaks  up  into  branches  which  supply  the  lacrimal 
gland,  the  conjunctiva,  and  the  upper  eyelid. 

The  nasal  nerve  passes  obhquely  forward  from  the 
sphenoid  fissure,  between  the  two  heads  of  the  external 
rectus  muscle,  to  the  anterior  ethmoid  foramen.  It  divides 
here  into  the  internal  nasal  and  the  infratrochlear  nerves. 

The  branches  of  the  nasal  nerve  are:  Branch  to  dura 
mater,  branch  to  ophthalmic  ganghon,  long  ciUary, 
posterior  ethmoid,  infratrochlear,  internal  nasal,  and 
external  branches,  which  are  septal,  lateral,  and  anterior. 

The  internal  nasal  nerve  passes  through  the  anterior 
ethmoid  foramen  into  the  brain-case  beside  the  cribri- 
form plate.  It  then  enters  the  nasal  sHt  beside  the 
crista  galli,  passes  into  the  nasal  chamber,  and  breaks  up 
into  the  terminal  branches,  septal,  lateral,  and  anterior. 

The  Maxillary  Division. — The  maxillary  division 
passes  forward  from  the  Gasserian  ganglion,  and  leaves 
the  cranium  through  the  foramen  rotundum.  It  crosses 
the  sphenomaxillary  fossa,  and  enters  the  orbit  through 
the  sphenomaxillary  fissure.  The  nerve  then  becomes 
the  infra-orbital,  enters  the  infra-orbital  canal  in  the 
floor  of  the  orbit,  and  runs  forward  to  open  on  the  face 
at  the  infra-orbital  foramen,  where  it  breaks  up  into  its 
terminal  filaments.  The  branches  of  the  maxillary 
nerve  are:  Meningeal,  orbital  or  temporomalar,  spheno- 
palatine, superior  dental,  and  infra-orbital. 

The  meningeal  branch  is  given  off  within  the  cranium 
and  passes  to  the  dura  mater. 

The  orbital,  or  temporomalar  branch,  is  given  off  in 
the  sphenomaxillary  fossa.  It  enters  the  orbit  through 
the  sphenomaxillary  fissure,  and  divides  into  two 
branches,  the  temporal  and  the  malar.     The  temporal 


78  APPLIED  ANATOMY 

branch,  after  giving  off  a  filament  which  communicates 
with  the  lacrimal  nerve,  passes  into  the  temporal  fossa 
through  the  sphenomalar  canal.  It  pierces  the  tem- 
poral muscle,  and  is  distributed  to  the  skin  of  the  region. 
The  malar  branch  passes  through  the  malar  canal  to 
supply  the  skin  over  the  malar  bone. 

The  sphenopalatine  branches,  two  in  number,  are  given 
off  in  the  sphenomaxillary  fossa,  and  pass  to  Meckel's 
ganglion,  forming  its  sensory  roots. 

The  superior  dental  branch  is  given  off  in  the  spheno- 
maxillary fossa,  and  passes  through  the  posterior  dental 
canals  to  supply  the  upper  molar  and  premolar  teeth  and 
the  gums. 

The  infra-orhital  nerve  is  the  terminal  branch  of  the 
maxillary  division  of  the  trifacial.  It  lies  in  the  infra- 
orbital canal,  and  opens  on  the  face  at  the  infra-orbital 
foramen,  where  it  breaks  up  into  its  terminal  branches. 
This  nerve  sends  a  branch  down  in  the  anterior  wall  of 
the  maxillary  sinus,  which  supplies  sensation  to  the 
canine  and  incisor  teeth  of  the  upper  jaw  and  the  muco- 
periosteum  of  the  maxillary  sinus. 

The  Mandibular  Division. — The  third  or  mandibular 
division  of  the  trifacial  is  its  largest  branch.  It  is  formed 
by  the  junction  of  the  third  portion  of  the  sensory  root 
from  the  Gasserian  ganglion  with  the  motor  root. 
The  two  leave  the  cranium  separately  through  the  for- 
amen ovale,  and  unite  immediately  afterward  to  form 
one  trunk.  About  a  quarter  of  an  inch  lower  down,  be- 
hind the  external  pterygoid  muscle,  the  trunk  branches 
into  a  smaller  anterior  and  a  larger  posterior  division. 
The  branches  of  the  mandibular  nerve  may  be  divided 
into  three  groups,  as  follows: 


THE   CRANIAL   NERVES  79 

{a)  From  the  main  trunk:  Recurrent  branch,  and  nerve 
to  the  internal  pterygoid  muscle. 

The  recurrent  branch  enters  the  cranium  through  the 
foramen  spinosum,  and  is  distributed  to  the  mastoid 
cells  and  the  petrous  portion  of  the  temporal  bone. 

The  nerve  to  the  internal  pterygoid  is  the  motor  nerve 
to  the  muscle  named.  It  also  contains  sensory  fibers 
which  pass  to  the  otic  ganghon. 

(6)  Branches  from  the  anterior  division:  Deep  temporal, 
masseteric,  external  pterygoid,  buccal.  These  branches 
supply  motor  fibers  to  the  muscles  named. 

{c)  Branches  from  the  posterior  division:  Auriculotem- 
poral, lingual,  and  inferior  dental. 

The  auriculotemporal  nerve  passes  up  with  the  super- 
ficial temporal  artery  to  supply  the  skin  of  the  auricle 
and  the  temple. 

The  lingual  nerve  runs  downward  and  forward  on  the 
internal  pten,^goid  muscle  to  the  inner  side  of  the  lower 
jaw,  near  the  last  molar  tooth,  where  it  Hes  just  under 
the  mucous  membrane.  It  then  runs  forward  to  the  tip 
of  the  tongue.  The  lingual  nerve  is  joined  behind  the 
ramus  of  the  jaw  by  the  chorda  tympani  nerve.  The 
lingual  nerve  supplies  common  sensation  to  the  tongue. 

The  inferior  dental  nerve  passes  downward  and  enters 
the  cribriform  tube  of  the  mandible  through  the  inferior 
dental  (mandibular)  foramen.  It  passes  forward  to  the 
symphysis  menti,  and  then  recurs  to  open  on  the  face  as 
the  mental  nerve  at  the  mental  foramen. 

The  branches  of  the  inferior  dental  nerve  are:  Mylo- 
hyoid, dental  and  gingival,  and  mental. 

The  mylohyoid  nerve  is  given  off  just  before  the  in- 
ferior dental  nerve  enters   the  mandibular  canal.     It 


8o  APPLIED  ANATOMY 

runs  along  the  mylohyoid  groove  of  the  mandible  with 
the  mylohyoid  vessels,  and  carries  motor  fibers  to  the 
mylohyoid  muscle  and  the  anterior  belly  of  the  digastric 
muscle. 

The  dental  and  gingival  branches  pass  up  the  tubules 
coming  off  from  the  main  tube  of  the  mandible,  to  supply 
the  teeth  and  gums. 

The  mental  nerve  is  the  terminal  branch  of  the  inferior 
dental.  After  emerging  from  the  mental  foramen,  it 
breaks  up  into  filaments  which  supply  the  skin  of  the 
chin  and  lower  lip. 

Sympathetic  ganglia  associated  with  the  trifacial  nerve. 

These  ganglia  are  four  in  number,  and  are  as  follows: 
Ophthalmic,  sphenopalatine,  otic,  and  submaxillary. 

These  ganglia  supply  sympathetic  fibers  to  the  various 
parts  to  which  their  branches  are  distributed,  for  ex- 
ample, motor  fibers  to  the  ciliary  muscle,  secretory  to 
the  submaxillary  gland,  etc. 

The  ophthalmic,  ciHary,  or  lenticular  ganglion  is  a 
small  body,  about  the  size  of  a  pin-head,  situated  in  the 
back  of  the  orbit,  between  the  optic  nerve  and  the 
external  rectus  muscle.  Its  sensory  root  is  derived  from 
the  nasal  branch  of  the  trifacial  nerve.  Its  motor  root 
is  derived  from  the  internal  oblique  branch  of  the  oculo- 
motor nerve.  Its  sympathetic  root  is  derived  from  the 
cavernous  plexus. 

The  branches  of  the  ophthalmic  ganglion  are  the  short 
ciliary  nerves,  eight  to  ten  in  number,  which  pass  to 
the  ciHary  muscle  of  the  eyeball. 

The  sphenopalatine,  or  MeckeVs  ganglion,  is  situated 
in  the  sphenomaxillary  fossa,  near  the  maxillary  division 
of  the  trifacial  nerve.     Its  sensory  roots  are   two  in 


THE    CRANIAL   NERVES  8 1 

number,  and  are  the  sphenopalatine  branches  of  the 
maxillary  nerve.  The  motor  and  sympathetic  roots  are 
combined  as  the  Vidian  nerve.  This  nerve  is  formed  by 
the  great  superficial  and  great  deep  petrosal  nerves. 

The  great  superficial  petrosal  nerve  is  the  motor  root 
of  Meckel's  ganglion,  and  is  derived  from  the  facial  nerve."^ 
The  great  deep  petrosal  nerve  is  the  sympathetic  root,  and 
is  derived  from  the  carotid  plexus  of  the  sympathetic. 

The  branches  of  Meckel's  ganglion  are — (a)  Ascend- 
ing, (6)  internal,  (c)  descending,  ((/)  posterior. 

The  ascending  branches  are  small  twigs  to  the  perios- 
teum of  the  orbit  and  the  mucous  membrane  of  the 
sphenoid  and  posterior  ethmoid  sinuses. 

The  internal  or  anterior  branches  supply  the  mucous 
membrane  of  the  nose  and  roof  of  the  mouth  as  the  naso- 
palatine nerve,  which  passes  through  the  anterior 
palatine  canal  and  foramen  of  Scarpa. 

The  descending  branches  are  the  anterior,  posterior, 
and  external  palatine  nerves.  The  anterior  palatine  nerve 
descends  through  the  posterior  palatine  canal,  runs 
forward  on  the  hard  palate  to  supply  the  mucous  mem- 
brane of  the  mouth,  and  communicates  with  the  naso- 
palatine nerve.  The  posterior  palatine  nerve  passes 
through  one  of  the  accessory  palatine  canals  to  the  uvula, 
tonsil,  and  soft  palate.  The  external  palatine  nerve 
passes  through  the  other  accessory  palatine  canal  to 
supply  the  tonsil  and  soft  palate. 

The  posterior  branches  of  Meckel's  ganglion  pass  to  the 
nasopharynx. 

The  otic  ganglion  lies  on  the  mandibular  nerve  just 
after  it  leaves  the  foramen  ovale.  Its  motor  and  sen- 
sory roots  reach  it  through  the  nerve  to  the  internal 


82 


APPLIED  ANATOMY 


pterygoid  muscle.  Its  sympathetic  root  is  derived  from 
the  plexus  around  the  middle  meningeal  artery.  It 
sends  branches  to  the  parotid  gland,  motor  twigs  to 
the  tensor  palati  and  tensor  tympani  muscles,  and  a 
communicating  branch  to  the  chorda  tympani  nerve. 

The  submaxillary  or  submandibular  ganglion  lies  on 
the  submaxillary  gland,  and  is  connected  with  the  man- 
dibular division  of  the  trifacial  nerve.  Its  sensory  root 
comes  from  the  trifacial  nerve  through  the  lingual 
branch.  Its  motor  root  is  derived  from  the  facial  through 
the  chorda  tympani.  Its  sympathetic  root  is  derived 
from  the  plexus  around  the  facial  artery.  This  ganghon 
sends  branches  to  the  submaxillary  gland,  Wharton's 
duct,  and  the  sublingual  gland. 


TABLE   OF   SYMPATHETIC    GANGLIA,   ASSOCIATED    WITH 
FIFTH   NERVE 


Name. 

Division. 

Sensory 
root. 

Motor 
root. 

Sympathetic 
root. 

Branches  and  distri- 
bution. 

Ophthal- 

Ophthal- 

Nasal 

Internal 

Cavernous 

Short  ciliary  nerves  to 

mic. 

mic. 

branch  of 
trifacial. 

oblique 
branch  of 
oculomotor. 

plexus. 

ciliary  muscle. 

Spheno- 

Maxillary. 

Spheno- 

Great    su- 

Great deep 

(a)   Ascending,  to  or- 

palatine 

palatine 

perficial 

petrosal 

bit,    sphenoid,    and 

or 

branches 

petrosal 

from  caro- 

ethmoid sinuses. 

Meckel's. 

of  maxil- 

branch of 

tid  plexus, 

(b)    Internal   or  ante- 

lary. 

seventh. 

through 

rior,      to       mucous 

through 

Vidian. 

membrane    of    nose 

Vidian. 

and  mouth,  as  naso- 
palatine. 

(c)  Descending,  as  an- 
terior, posterior,  and 
external         palatine 
nerves,    to    mucous 
membrane  of  palate 
and  tonsils. 

(d)  Posterior,  to  naso- 
pharynx. 

Otic. 

Mandibu- 

Internal 

Internal 

Plexus 

Parotid   gland,  tensor 

lar. 

pterygoid 

pterygoid 

around  mid- 

tympani, and  tensor 

branch  of 

branch  of 

dle  menin- 

palati muscles. 

trifacial. 

trifacial. 

geal  artery. 

Submax- 

Mandibu- 

Lingnal 

Facial 

Plexus 

Submaxillary     gland. 

illary. 

lar. 

branch  of 

through 

around 

Wharton's  duct, sub- 

trifacial. 

chorda 
tympani. 

facial 
artery. 

lingual  gland. 

THE    CRANIAL   NERVES 


83 


Ophthalmic. 


TABLE    OF    THE    FIFTH    NERVE    AND    ITS    BRANCHES 

f  Supratrochlear. 
I  Supra-orbital, 
j  Superior  branch. 
I  Inferior  branch. 

Branch  to  dura  mater. 

Branch  to  ophthalmic  ganglion. 

Long  ciliary.        f  Septal. 

Internal  nasal. .  <.  Lateral. 
(^  Anterior, 
f  Temporal. 
1  Malar. 


Maxillary. 


Frontal 


Lacrimal 


Nasal. 


Temporomalar. 


Sphenopalatine. 

Superior  dental.       r  ^  ,     , 

Palpebral. 

Infra-orbital J    Nasal. 

Labial. 


Mandibular. 


From  main  trunk . 


Anterior  division. 


Posterior  division. 


f  Recurrent. 

I  Internal  pterygoid. 

r  Deep  temporal. 

Masseteric. 

External  pterygoid. 
1^  Buccal. 

Auriculotemporal. 

Lingual.  C  Mylohyoid. 

Inferior  dental.  <  Dental. 
(,  Mental. 


THE  Seventh  Nerve 

The  seventh  cranial  or  facial  nerve  (Fig.  2  2)  is  the  motor 
nerve  to  the  muscles  of  expression  of  the  face,  and  also 
supplies  the  scalp,  external  ear,  platysma  myoides,  buccina- 
tor, posterior  belly  of  the  digastric,  and  stylohyoid  muscles. 

The  deep  origin  of  the  facial  nerve  is  in  the  floor  of  the 
fourth  ventricle.  Its  superficial  origin  is  from  the  med- 
ulla, between  the  olivary  and  restiform  bodies. 

The  facial  nerve  enters  the  internal  auditory  meatus 
in  company  with  the  auditory  nerve.     At  the  end  of  the 


84 


APPLIED  ANATOMY 


meatus  it  passes  into  a  narrow  bony  canal,  the  aqueductus 
Fallopii.  This  canal  has  a  tortuous  course  through  the 
petrous  portion  of  the  temporal  bone,  and  terminates  at 
the  stylomastoid  foramen,  where  the  facial  nerve  makes 
its  exit  from  the  skull.  It  breaks  up  into  its  terminal 
branches  in  the  substance  of  the  parotid  gland. 


Fig.  22.— Branches  of  the  facial  nerve  spread  over  the  face  like  a  fan  (Campbell). 

The  branches  of  the  facial  nerve  are  divided  into  two 
groups :  {a)  Before  its  exit  from  the  stylomastoid  foramen. 
Nerve  to  stapedius  muscle,  chorda  tympani,  connecting 
branches  with  pneumogastric,  branches  to  glosso- 
pharyngeal. 

The  nerve  to  the  stapedius  passes  through  a  fine  bony 
canal  and  supplies  the  muscle  named. 


THE   CRANIAL   NERVES  85 

The  chorda  tympani  nerve  passes  in  a  bony  canal 
through  the  petrous  portion  of  the  temporal  bone, 
crosses  the  tympanic  cavity,  enters  the  canal  of  Huguier 
at  the  side  of  the  Glaserian  fissure,  and  unites  with 
the  Ungual  branch  of  the  trifacial  nerve,  under  the  lower 
border  of  the  internal  pterygoid  muscle.  The  chorda 
tympani  probably  originates  from  the  glossopharyngeal, 
and  carries  fibers  of  the  special  sense  of  taste.  The 
communicating  branches  pass  to  ganglia  of  the  pneumo- 
gastric  and  glossopharyngeal  nerves. 

ih)  After  the  exit  of  the  seventh  nerve  from  the  stylo- 
mastoid foramen:  Posterior  auricular,  stylohyoid,  digastric, 
styloglossal,  temporofacial,  cervicofacial. 

The  posterior  auricular  nerve  arises  near  the  stylo- 
mastoid foramen.  It  passes  backward  and  divides  into 
auricular  and  occipital  branches.  The  auricular  branch 
supplies  the  retrahens  aurem,  and  the  occipital  supplies 
the  occipitalis  muscle. 

The  stylohyoid  nerve  supplies  the  muscle  named. 

The  digastric  branch  is  distributed  to  the  posterior 
belly  of  the  digastric  muscle. 

The  styloglossal  branch  supplies  the  styloglossus  and 
stylopharyngeus  muscles. 

The  temporofacial  division  passes  upward  and  forward 
in  the  substance  of  the  parotid  gland  and  breaks  up 
into  three  branches:  (a)  Temporal,  to  the  muscles  of  the 
temple  and  side  of  the  forehead,  (b)  Malar,  to  orbicu- 
laris palpebrarum  and  corru gator  supercilii.  (c)  Infra- 
orbital, to  the  muscles  connected  with  the  upper  lip. 

The  cervicofacial  division  passes  downward  and  forward 
in  the  substance  of  the  parotid  gland,  and  breaks  up 
into  the  following  branches:  (a)  Buccal,  to  the  buccinator 


86  APPLIED  ANATOMY 

and  orbicularis  oris  muscles.  (5)  Supramaxillary,  to 
the  muscles  of  the  lower  lip  and  chin,  (c)  Inframaxillary, 
to  the  platysma  myoides. 

The  geniculate  ganglion  is  situated  on  a  bend  of  the 
facial  nerve  in  the  aqueductus  Fallopii.  Its  branches 
are  as  follows: 

{a)  Great  superficial  petrosal  nerve. 

(6)  Small  superficial  petrosal  nerve. 

(c)  Branches  to  the  sympathetic  system. 

{d)  Branches  to  the  tympanic  plexus. 

{e)  Branches  to  the  pneumogastric  nerve. 

(/)  Branches  to  the  glossopharyngeal  nerve. 

The  great  superficial  petrosal  nerve  passes  through  the 
hiatus  Fallopii  on  the  anterior  suriace  of  the  petrous 
portion  of  the  temporal  bone,  then  inward  beneath  the 
Gasserian  ganglion  to  the  middle  lacerated  foramen. 
Here  it  joins  the  great  deep  petrosal  nerve,  and  with  it 
passes  through  the  Vidian  canal  in  the  sphenoid  bone  as 
the  Vidian  nerve,  and  enters  Meckel's  ganglion  as  its 
motor  root. 

The  small  superficial  petrosal  nerve  joins  the  otic 
ganglion  as  its  motor  root. 

The  branches  to  the  sympathetic  system  pass  to  the  plexus 
around  the  middle  meningeal  artery  and  tympanic  plexus. 

It  is  generally  taught  that  the  facial  is  purely  a  motor 
nerve.  Studies  of  cases  in  which  the  Gasserian  ganglion 
had  been  removed  or  the  function  of  the  fifth  nerve  other- 
wise completely  destroyed,  tend  to  show  that  sensibility 
to  deep  pressure  over  the  facial  muscles  in  these  cases 
is  still  present  to  a  certain  extent.  From  this  it  may  be 
assumed  that  the  facial  nerve  contains  fibers  of  deep 
sensibility  from  the  muscles  supplied  by  it. 


After  exit  from  stylomastoid  foramen. 


THE    CRANIAL   NERVES  87 

TABLE  OF  THE  SEVENTH  NERVE   AND   ITS   BRANCHES. 

\  Stapedius. 

Before   exit  from  stylomastoid  fora-  J  Chorda  tympani. 

men '  Branch  to  pneumogastric. 

[  Branch  to  glossopharyngeal. 

r  „         .  .     ,       f  Auricular. 

I  Posterior  auricular.  ,  ^    .  .    , 
V  Occipital. 

Stylohyoid. 

Digastric. 

Styloglossal. 

[  Temporal. 

Temporofacial.  \  Malar. 

[  Infra-orbital. 

[Buccal. 

Cervicofacial.  \  Supramaxillary. 

[  Inframaxillary. 

Review  Questions 

Name  the  cranial  nerves  in  their  regular  order,  giving  their  foramina 
of  exit  from  the  brain-case,  distribution,  and  function. 

Give  the  deep  and  superficial  origins  of  the  fifth  nerve. 

Give  the  name,  position,  and  branches  of  the  sensory  ganglion  of  the 
fifth  nerve. 

Give  the  course  of  the  motor  root  of  the  trifacial  nerve. 

Name  the  three  divisions  of  the  trifacial  nerve,  giving  their  foramina 
of  exit  from  the  skull. 

Give  the  branches  of  the  ophthalmic  division  of  the  trifacial  nerve. 

Give  the  branches  of  the  maxillary  division  of  the  trifacial  nerve. 

Give  the  branches  of  the  mandibular  division  of  the  trifacial  nerve. 

What  sympathetic  ganglia  are  connected  with  the  fifth  nerve?  Give 
their  positions,  roots,  and  branches. 

What  are  the  functions  of  the  fifth  nerve? 

Ciive  the  deep  and  superficial  origins  of  the  seventh  nerve. 

Give  the  course  of  the  seventh  nerve  from  its  superficial  origin  to  its 
terminal  branches. 

Give  the  branches  of  the  facial  nerve. 

Give  the  name,  position,  and  branches  of  the  ganglion  associated  with 
the  seventh  nerve. 

What  are  the  functions  of  the  seventh  nerve? 


CHAPTER  VII 


GLANDS 


The  special  mucous  and  salivary  glands  associated 
with  the  oral  cavity  are  the  parotid,  submaxillary,  sub- 
lingual, labial,  buccal,  Hngual,  and  palatal  glands. 


Parotid  Gland 


The  parotid  gland  (Fig.  23)  is  the  largest  of  the  sali- 
vary glands,    its  weight   averaging   one   ounce.     It  is 


Fig.  23. — The  parotid  gland  (Campbell). 

a   compound    racemose,    salivary   gland,   its    principal 
secretion  being  ptyahn,  an  amylolytic  ferment. 


GLANDS  89 

The  parotid  gland  is  situated  in  the  parotid  space. 
This  triangular  space  is  bounded  in  front  by  the  ramus 
of  the  mandible;  behind,  by  the  mastoid  and  styloid 
processes  and  the  tympanic  portion  of  the  temporal 
bone;  and  below,  by  a  line  drawn  from  the  angle  of  the 
mandible  to  the  tip  of  the  mastoid  process.  The  gland 
does  not  exactly  conform  to  the  conlines  of  this  space,  but 
overlaps  its  boundaries.  The  deep  portion  of  the  gland 
passes  inward  and  comes  into  relation  with  the  vertebra? 
and  base  of  the  skull.  The  upper  portion  passes  into 
the  posterior  part  of  the  glenoid  fossa.  The  anterior 
portion  overlaps  the  masseter  muscle.  The  accessory 
parotid  or  socia  parotidis,  when  present,  lies  on  the 
masseter  muscle  below  the  zygomatic  arch.  The  parotid 
gland  is  invested  by  processes  of  the  deep  cervical  fascia. 

The  duct  of  the  parotid  gland,  or  Stenson's  duct,  is 
about  two  and  a  half  inches  long,  and  varies  in  diameter, 
its  orifice  being  its  narrowest  part,  only  permitting 
the  entrance  of  a  small  probe.  The  duct  runs  forward 
across  the  face  from  the  anterior  border  of  the  parotid 
gland,  about  a  finger's  breadth  below  the  zygoma,  over 
the  masseter  muscle,  curves  inward  to  pierce  the  buc- 
cinator muscle,  and  opens  in  the  vestibule  of  the  mouth 
in  a  papilla  opposite  the  upper  second  molar  tooth. 

The  blood-supply  of  the  parotid  gland  is  derived 
from  the  external  carotid,  internal  maxillary,  superficial 
temporal,  transverse  facial,  and  posterior  auricular 
arteries.  The  veins  follow  a  similar  course  to  the  ar- 
teries. 

The  nerves  are  derived  from  the  facial,  auriculo- 
temporal, great  auricular,  and  the  sympathetic  plexus 
of  the  external  carotid  artery. 


90  APPLIED  ANATOMY 

The  external  carotid  artery  and  its  terminal  branches 
and  the  facial  nerve  pass  through  the  substance  of  the 
parotid  gland. 

The  parotid  lymphatic  glands  he  upon  it  and  within 
its  substance. 

The  Submaxillary  Gland 

The  submaxillary  gland  is  a  compound  racemose 
gland  and  secretes  a  mucosalivary  fluid.  It  is,  there- 
fore, a  mixed  gland.  It  is  smaller  than  the  parotid 
gland,  being  about  the  size  of  a  hazel-nut.  The  sub- 
maxillary gland  is  situated  in  the  submaxillary  fossa,  on 
the  inner  side  of  the  body  of  the  mandible.  Above  and 
in  front  of  the  gland  is  the  mylohyoid  muscle,  which 
separates  it  from  the  sublingual  gland.  Behind,  the 
submaxillary  gland  is  separated  from  the  parotid  gland 
by  the  stylomandibular  ligament.  In  relation  to  the 
neck  the  submaxihary  gland  lies  in  the  submaxillary 
triangle,  and  is  covered  by  the  skin,  superficial  fascia, 
platysma  myoides,  which  lies  in  the  superficial  fascia, 
and  the  deep  fascia. 

The  outlet  of  the  submaxillary  gland  is  known  as  the 
duct  of  Wharton.  This  runs  backward  under  the  mylo- 
hyoid muscle,  around  the  posterior  edge  of  the  muscle, 
and  over  its  upper  surface,  to  open  through  the  floor  of 
the  mouth  in  a  papilla  at  the  base  of  the  tongue. 

The  blood-supply  to  the  submaxillary  gland  is  derived 
from  the  submaxillary  branch  of  the  facial  artery.  Its 
nerve-supply  is  from  the  submaxillary  ganglion. 


GLANDS  91 

The  Sublingual  Gland 

The  sublingual  gland  is  smaller  than  the  submaxillary 
gland.  It  is  a  compound  racemose  gland  and  secretes 
mucus  only.  The  sublingua,!  gland  is  situated  in  the 
sublingual  fossa  of  the  inner  surface  of  the  body  of  the 
mandible,  immediately  beneath  the  mucous  membrane 
of  the  mouth.  Below  it  is  the  mylohyoid  muscle.  The 
gland  consists  of  several  small  lobes,  which  open  into 
the  floor  of  the  mouth  by  separate  small  ducts,  the 
ducts  of  Rivinus,  eight  to  twenty  in  number.  A  larger 
duct,  the  duct  of  Bartholin,  runs  from  the  posterior 
lobules  and  empties  into  Wharton's  duct. 

The  labial,  buccal,  lingual,  and  palatal  glands  are 
small  racemose  or  compound  tubular  glands,  situated 
in  the  mucous  membrane  covering  the  lips,  cheeks, 
tongue,  and  hard  and  soft  palate,  which  secrete  mucus. 

Review  Questions 

Name  the  mucous  and  salivary  glands  which  empty  into  the  oral 
cavity. 

Describe  the  parotid  gland,  giving  its  position,  relations,  duct,  and 
function. 

Describe  the  submaxillary  gland,  giving  its  position,  relations,  duct, 
and  function. 

Describe  the  sublingual  gland,  giving  its  position,  relations,  duct, 
and  function. 

What  is  the  function  of  the  lingual,  labial,  buccal,  and  palatal  glands? 


CHAPTER  VIII 
THE  TONSILS  AND  THE  MOUTH 

The  Tonsils 

The  tonsils  (Fig.  24)  are  two  oval  masses  of  lymphoid 
tissue,  situated  one  on  either  side  of  the  tonsillar  space. 
This  space  is    found    between   the  anterior   and  pos- 


Fig.  24. — Surface  markings  shown  within  the  mouth:  A,  Hard  palate;  B,  soft 
palate;  C,  uvula;  D,  pillars  of  fauces;  E,  tonsils  (Campbell). 

terior  pillars  of  the  fauces.  The  anterior  pillars  of 
the  fauces  are  formed  by  the  palatoglossus  muscles 
and  the  posterior  pillars  by  the  palatopharyngeus  mus- 
cles   (Fig.    25).      Externally,  the  tonsil  is  in  relation 

92 


THE    TONSILS  AND    THE   MOUTH 


93 


with  the  superior  constrictor  muscle  of  the  pharynx, 
which  separates  it  from  the  internal  carotid  artery. 
This  artery  has  been  wounded  in  operations  on  the  tonsil. 


Superior  longitudinal  sinu 


ferior  longitudinal  sinus 
Falx  cerebri 


Temporosphenoid 

lobe 
Posterior  part  of 

orbit 
Temporal  muscle 


Z\goma 

External  pterygoiu 

Ramub  of  mandible 


Soft  palate 


Uvula 

External  pterygoid 


Palatopharyugeus 
Palatoglossus 


Hyoid  bone 

Thyrohyoid  muscle 

Thyroid  cartilage 

Omohyoid 

Sternocleidomastoid 

Cricoid  cartilage 


Fig.  25. — Vertical  transverse  section  of  a  frozen  head  (after  Cryer). 


The  ascending  pharyngeal  artery  is  more  likely  to  be 
injected,  but  is  a  much  smaller  vessel,  and  is  not  likely  to 
give  rise  to  serious  hemorrhage  if  divided.     The  tonsil  is 


94  APPLIED  ANATOMY 

composed  of  lymphoid  tissue  arranged  in  follicles.  It 
is  covered  with  stratified  squamous  epithelium.  On 
the  proximal  surface  of  the  tonsil  are  several  depressions 
or  crypts,  lined  with  squamous  epithelium,  into  which 
open  a  number  of  mucous  glands.  These  crypts  some- 
times become  clogged  by  secretion,  giving  rise  to  inflam- 
mation of  the  tonsil. 

The  blood-supply  of  the  tonsils  is  derived  from  the 
tonsillar  and  ascending  palatine  branches  of  the  facial 
artery,  the  descending  palatine  branch  of  the  internal 
maxillary  artery,  and  the  ascending  pharyngeal  artery. 

The  functions  of  the  tonsils  are  obscure.  The  fact 
that  they  atrophy  about  puberty  unless  diseased  shows 
some  connection  with  the  growth  of  the  individual. 
They  are  believed  to  act  as  filters  which  prevent  the 
absorption  of  disease  germs  through  the  throat.  On 
the  other  hand,  there  is  abundant  evidence  to  show  that 
many  diseases  gain  entrance  through  the  tonsils. 

In  addition  to  the  faucial  tonsils,  there  are  other 
masses  of  lymphoid  .tissue  known  as  the  lingual  and 
pharyngeal  tonsils. 

The  Mouth 

The  oral  cavity  consists  of  a  roof,  a  floor,  lateral  walls, 
vestibule,  an  inlet,  and  an  outlet. 

The  Yoo]  of  the  mouth  is  formed  by  the  hard  palate  in 
front  and  the  soft  palate  behind. 

"  The  hard  and  soft  palates  should  be  described  as 
extending  from  the  anterior  teeth  backward  and  slightly 
down  in  a  concave  line  to  near  the  postpharyngeal  wall, 
leaving  scarcely  any  space.  In  the  normal  living  sub- 
ject, when  the  mouth  is  closed,  the  soft  palate,  the 


THE    TONSILS  AND    THE  MOUTH  95 

posterior  border  of  the  tongue,  and  the  epiglottis  are  all 
in  close  proximity  to  the  post-pharyngeal  wall  "  (Cryer) 
(Fig.  14). 

The  floor  of  the  mouth  is  composed  of  the  two  mylo- 
hyoid muscles,  which  join  in  the  median  line  to  form  a 
raphe.  Above  the  mylohyoid  muscle  is  the  sublingual 
gland,  while  below  it  is  the  submaxillary  gland.  Pos- 
teriorly is  the  base  of  the  tongue,  and  anteriorly  are  the 
alveolar  process  and  the  lower  anterior  teeth. 

The  mouth  is  bounded  laterally  by  the  cheeks. 

The  vestibule  of  the  mouth  is  the  pocket  between  the 
outer  side  of  the  alveolar  processes  and  teeth  and  the 
inner  surface  of  the  cheek. 

The  i}ilet  of  the  mouth  is  surrounded  by  the  orbicu- 
laris oris  muscle,  forming  the  lips.  Just  within  this  are 
the  upper  and  lower  anterior  teeth. 

The  outlet  of  the  mouth  is  bounded  above  by  the 
uvula  and  posterior  edge  of  the  soft  palate,  laterally  by 
the  pillars  of  the  fauces  and  the  tonsils,  and  below  by 
the  dorsum  of  the  tongue. 

Review  Questions 

Give  the  structure,  position,  relation,  blood  supply,  and  functions 
of  the  faucial  tonsil. 

What  other  tonsils  are  there? 

Describe  the  roof  of  the  oral  cavity. 

Describe  the  floor  oi  the  mouth,  giving  the  structures  in  close  rela- 
tion to  it. 

What  structures  form  the  outlet  of  the  mouth? 


PART   II 
ORAL  SURGERY 


General  Considerations 


CHAPTER    IX 

ABNORMAL   CONDITIONS    OF    THE    CIRCULATION  AND 
COMPOSITION  OF  THE  BLOOD 

By  hyperemia,  or  congestion,  is  meant  an  excessive  sup- 
ply of  blood  in  a  part.  It  may  be  active,  in  which  case 
there  is  an  increase  in  the  moving  blood,  due  to  dilatation 
of  arterioles  and  capillaries,  or  passive,  in  which  the  blood 
is  stagnant,  due  to  venous  obstruction.  In  hyperemia 
the  elements  of  the  blood  remain  within  the  vessels,  as 
distinguished  from  the  further  process  of  inflammation. 

By  anemia  is  meant  a  deficient  supply  of  blood  to  a 
part,  or  a  defect  in  the  composition  of  the  blood.  The 
degree  of  anemia  is  measured  by  the  percentage  of 
hemoglobin  as  compared  with  that  of  normal  blood,  and 
by  the  number  of  red  corpuscles  (erythrocytes)  in  a 
given  quantity  of  blood  as  compared  to  the  normal  blood. 
In  normal  blood  the  percentage  of  hemoglobin  is  taken 
as  loo,  and  the  number  of  red  cells  as  5,000,000  per 
cubic  milHmeter.  Various  grades  of  anemia  are  recog- 
7  97 


98  ORAL   SURGERY 

nized  by  comparison  with  these  standards,  and  by  change 
in  the  ratio  borne  by  the  percentage  of  hemoglobin 
to  the  number  of  red  cells.  Severe  anemias  are  also 
characterized  by  alterations  in  size  and  shape  of  the  red 
corpuscles  (poikilocy tosis) ,  and  by  the  appearance  of 
nucleated  red  cells  and  granular  degeneration  of  the  cells. 
Two  general  classes  of  anemia  are  recognized,  primary 
and  secondary.  Secondary  anemia  may  be  due  to 
hemorrhage,  various  poisons,  as  lead,  phosphorus,  etc., 
wasting  diseases,  as  syphilis,  tuberculosis,  cancer,  and 
other  conditions,  as  intestinal  parasites.  Primary 
anemia  is  regarded  as  a  disease  originating  in  the  blood 
itself  or  in  the  blood-forming  organs,  though  it  is  probable 
that  ultimate  causes  will  be  found  for  this  class  also. 

The  leukocytes,  or  white  blood-corpuscles,  are  nor- 
mally  found  in  the  proportion  of  about  8000  to  the  cubic 
millimeter.  An  increase  in  their  number  is  known  as 
leukocytosis,  which  occurs  in  ordinary  acute  inflam- 
mation, sometimes  amounting  to  15,000,  20,000,  or 
50,000. 

In  inflammatory  leukocytosis  the  increase  is  chiefly 
in  the  polymorphonuclear  leukocytes.  Certain  diseases 
of  the  blood  and  blood-forming  organs  known  as  leu- 
kemias,  are  also  characterized  by  a  tremendous  increase 
in  the  number  of  certain  varieties  of  leukocytes,  and  the 
appearance  in  the  blood  of  new  forms. 

Active  h5^eremia  is  the  result  of  mild  irritation  of 
some  sort.  When  irritation  is  more  severe  or  is  kept  up, 
a  condition  of  inflammation  is  induced. 

Review  Question 

Define  hyperemia,  anemia,  leukocytosis,  leukemia. 


CHAPTER  X 

INFLAMMATION 

It  is  impossible  to  adequately  define  the  term  inflam- 
mation in  a  short  sentence,  owing  to  the  complex  nature 
of  the  process,  and  the  following  definitions  are  neces- 
sarily imperfect. 

Inflammation  is  an  expression  of  the  effort  on  the  part 
of  a  living  tissue  to  rid  itself  of  or  render  inert  noxious 
irritants,  arising  from  within  or  introduced  from  without. 
It  is  the  sum  of  the  pathologic  changes  taking  place  in 
a  part  as  the  result  of  injury,  and  characterized  by  heat, 
pain,  redness,  swelling,  and  disturbance  of  function. 

Inflammation  is  a  succession  of  local  adaptive  changes 
in  a  part  resulting  from  direct  or  referred  injury  (Adami). 

Etiology. — Anything  that  causes  local  injury  to  the 
tissues  is  a  cause  of  inflammation.  These  causes  are: 
(a)  Mechanical — trauma,  (b)  Chemical,  (c)  Physical 
— heat,  cold,  electricity,  (d)  MetaboHc — gout,  etc. 
(e)  Bacterial. 

The  presence  of  bacteria  is  not  essential  for  inflam- 
mation. 

There  are  two  grades  of  inflammation,  the  acute, 
running  a  rapid  course,  characterized  by  the  classic 
symptoms,  and  generally  due  to  microbic  invasion,  and 
the  chronic,  slow  in  development  and  progress,  in  which 
cardinal  symptoms  may  be  lacking.  All  grades  occur 
between  these  two  extremes. 

1)9 


lOO  OUAL   SURGERY 

Tissue  Changes  Occurring  in  Acute  Inflammation. — 

These  may  be  studied  under  the  microscope  in  the  web 
of  the  living  frog's  foot  or  mesentery,  and  also  by  pre- 
paring sections  of  tissue  in  different  stages  of  inflamma- 
tion. What  knowledge  we  have  has  been  gained  by  a 
combination  of  these  methods. 
These  changes  may  be  summed  up  as  follows: 

1.  Primary  contraction  of  blood-vessels,  and  increase 
in  rapidity  of  the  current. 

2.  Dilatation  of  the  vessels  and  gradual  slowing  of  the 
current. 

3.  Temporary  or  permanent  arrest  of  the  blood  cur- 
rent (stasis). 

4.  Emigration  of  leukocytes  through  the  vessel- walls 
into  the  surrounding  tissues. 

5.  Exudation  of  blood-serum,  and  diapedesis  of  red 
blood-corpuscles. 

There  is  a  primary  contraction  of  the  blood-vessels, 
due  to  the  irritation.  This  causes  a  temporary  increase 
in  the  velocity  of  the  blood-current.  The  vessels  now 
gradually  dilate,  and  the  current  becomes  slower  and 
slower  until  it  is  almost  entirely  arrested.  These 
phenomena  are  observed  solely  in  the  veins  and  capil- 
laries. The  slowing  of  the  current  is  believed  to  be 
due  to  changes  in  the  endothelia  of  the  veins.  While 
the  current  is  flowing  rapidly,  the  individual  cells  of  the 
blood  cannot  be  distinguished,  but  as  it  slows  down,  the 
leukocytes  are  observed  to  accumulate  in  the  outer  zone 
of  the  current,  along  the  walls  of  the  veins,  some  of  them 
becoming  fixed  there.  The  leukocytes  also  show  a 
tendency  to  cling  to  the  walls  of  the  capillaries  (mar- 
gination  of  leukocytes).     After  a  time  the  leukocytes 


IN  FLA  MM  A  TION  I  o  I 

are  observed  to  be  making  their  way  through  the  vessel 
walls.  The  first  indication  of  this  is  the  appearance  of 
a  small  portion  of  the  cell  on  the  outer  side  of  the  vessel- 
wall,  gradually  followed  by  the  whole  cell.  This  passage 
of  the  leukocytes  through  the  walls  of  the  veins  and 
capillaries  is  known  as  emigration.  The  white  blood- 
cells  are  beheved  to  pass  through  spaces  or  stomata 
between  the  endothelial  plates  lining  the  vessel-walls. 
The  leukocytes  which  have  left  the  vessels  may  pass 
through  the  tissue  spaces  to  the  seat  of  the  irritation, 
or  may  reenter  their  circulation  through  the  lymph 
vessels.  While  the  emigration  of  leukocytes  is  going  on, 
red  cells  and  blood-serum  find  their  way  into  the  sur- 
rounding tissues,  principally  through  the  walls  of  the 
capillaries.  The  extravasation  of  red  cells  is  known  as 
diapedesis.  The  serum  extravasated  differs  somewhat 
in  composition  from  normal  blood  plasma,  being  richer 
in  proteins. 

Inflammation  may  terminate  in  resolution  without 
pus  formation,  or  suppuration  may  supervene  before 
resolution. 

In  the  inflammatory  process  the  leukocytes  pass  to 
the  point  of  irritation,  which  is  generally  due  to  bacteria, 
gather  around  the  infected  area,  and  attempt  to  neutral- 
ize the  action  of  the  bacteria  and  their  products.  This 
action  of  the  leukocytes  is  called  phagocytosis.  The 
leukocytes  can  be  shown  to  absorb  the  bacteria  into 
themselves  and  digest  them.  Other  body  cells  and  tis- 
sues form  substances  that  neutralize  the  toxic  effects 
of  the  bacteria  and  prepare  them  for  ingestion  by  the 
leukocytes.  In  primary  resolution  after  inflammation 
there  is  no  death  of  tissue,  which  returns  to  a  normal 


I02  ORAL   SURGERY 

condition  by  absorption  into  the  circulation  of  the  inflam- 
matory exudates. 

Sometimes  the  resistive  powers  of  the  body  are  not 
sufficiently  powerful  to  overcome  the  bacteria,  which 
continue  to  grow  and  send  out  their  products,  resulting 
in  liquefaction  and  death  of  the  tissue-cells  and  leuko- 
cytes. This  process  is  known  as  suppuration.  Sooner 
or  later,  as  a  rule,  the  suppurative  process  becomes 
localized  or  walled  in  by  leukocytes.  The  liquefied 
necrotic  area  is  known  as  an  abscess,  and  the  material 
contained  in  it  is  called  pus.  Pus  is,  therefore,  com- 
posed of  fluid  containing  broken-down  leukocytes  and 
tissue-cells,  fat  globules,  albuminous  granules,  and  bac- 
teria. Pus  is  not,  as  a  rule,  absorbed,  but  gradually 
makes  its  way  in  the  direction  of  least  resistance,  toward 
the  surface  of  the  tissue  and  is  expelled.  The  communi- 
cation of  an  abscess  cavity  or  area  of  necrotic  tissue  with 
the  surface  of  the  body  is  known  as  a  sinus.  This  term 
should  not  be  confused  with  ^^/w/a,  which  is  a  pathologic 
communication  of  a  normal  cavity  or  hollow  viscus  with 
the  body  surface,  or  with  some  other  hollow  viscus. 
After  evacuation  of  an  abscess,  resolution  takes  place, 
new  tissue  being  formed  to  make  up  for  that  lost  by 
suppuration.  The  process  of  repair  of  tissues  will  be 
considered  under  Wounds. 

Symptoms  of  Inflammation. — The  cardinal  or  clas- 
sical symptoms  of  inflammation  are  heat  (calor),  pain 
(dolor),  redness  (rubor),  swelling  (tumor),  and  disturbed 
function  (functio  laesa).  These  symptoms  can  all  be 
explained  by  the  pathologic  changes  which  occur  in  an 
inflamed  tissue. 

Heat. — An  inflamed  part  is  usually  both  subjectively 


INFLAMMATION  IO3 

and  objectively  warmer  than  the  surrounding  tissues. 
The  temperature,  however,  is,  in  reality,  no  higher  than 
that  of  the  blood.  The  local  sensation  of  warmth  is  due 
to  the  increased  blood-supply  and  to  chemical  action. 

Pain  is  due  to  irritation  of  sensory  nerve-endings  by 
the  toxins  produced.  That  it  is  not  caused  by  pressure 
of  the  exudate  is  borne  out  by  the  anesthesia  produced  by 
injection  of  subcutaneous  tissues  with  physiologic  salt 
solution. 

Redness  is  due  to  distention  of  the  capillaries  of  the 
inflamed  part  with  blood. 

Swelling  is  caused  in  part  by  the  increased  amount 
of  blood  in  the  vessels,  but  is  chiefly  due  to  exudation  of 
blood-serum  into  the  tissues. 

Disturbed  Function. — This  naturally  results  from  the 
swelHng  and  pain. 

In  addition  to  the  classical  symptoms,  other  signs  are 
noted  in  the  various  stages  of  inflammation.  Some  are 
purely  local,  while  others  are  an  expression  of  a  general 
poisoning  of  the  system  by  absorption  of  toxins  into  the 
circulation. 

Edema,  or  pitting  on  pressure  of  the  skin  over  the 
inflamed  part,  is  usually  present  in  microbic  inflammation 
of  subcutaneous  tissues.  It  is  due  to  the  presence  of 
inflammatory  exudate. 

Fluctuation  is  a  sign  of  a  localized  collection  of  pus 
or  abscess. 

Fever,  or  elevation  of  temperature,  is  present  in  all 
microbic  infections  in  which  the  products  of  bacterial 
growth  are  absorbed  into  the  general  circulation.  It 
is  due  to  increased  heat  production  from  the  breaking 
down  of  tissues  by  bacterial  toxins.  The  rise  of  temper- 
ature is  always  accompanied  by  increased  pulse-rate. 


104  ORAL   SURGERY 

A  chill  often  precedes  the  formation  of  pus. 

Leukocytosis  is  found  in  nearly  all  acute  inflammatory 
conditions,  the  increase  being  chiefly  in  the  polymorpho- 
nuclear leukocytosis. 

Besides  these  symptoms,  we  may  have  muscular  weak- 
ness, anorexia  or  distaste  for  food,  headache,  delirium, 
and  other  disturbances  of  the  nervous  system.  The 
liver,  kidneys,  and  other  excretory  organs  may  be  affected. 

Treatment  of  Inflammation. — The  general  principles 
of  treatment  of  inflammation  consist  in  removal  of  the 
cause,  putting  the  parts  at  rest,  and  the  application  of  cold 
and  pressure.    When  pus  forms,  it  must  be  evacuated. 

Cellulitis. — When  the  leukocytes  fail  to  build  a  lim- 
iting wall  to  the  area  of  infection,  the  bacteria  spread 
in  the  tissue-spaces  and  along  the  lymph-channels  of  the 
subcutaneous  tissues.  This  process  is  known  as  cellulitis. 
It  may  result  in  diffuse  suppuration,  or,  in  more  severe 
cases,  where  there  is  extensive  tissue  destruction,  in 
phlegmonous  or  gangrenous  inflammation.  In  the  re- 
gion of  the  jaws  cellulitis  may  be  caused  by  an  infected 
tooth,  from  stomatitis,  from  infection  of  the  salivary 
glands,  or  from  an  impacted  third  molar.  The  cellu- 
litis from  an  abscessed  tooth  may  spread  down  the  neck 
between  the  layers  of  the  deep  fascia.  Where  it  is 
caused  by  an  impacted  third  molar,  the  inflammation 
generally  passes  upward  to  the  temporomandibular  ar- 
ticulation, causing  acute  ankylosis. 

Ulceration 

An  inflammatory  ulcer  is  the  result  of  suppuration  and 
tissue  destruction  in  close  connection  with  an  epidermal 


INFLAMMA  TION  I O  5 

or  mucous  surface,  causing  loss  of  these  layers.  The 
process  is  identical  with  that  of  abscess  formation,  and 
repair  takes  place  in  the  same  way. 

Tissue  surface  may  be  lost  by  injury  of  some  kind, 
resulting  in  the  formation  of  a  traumatic  ulcer.  The 
surface  may  also  break  down  from  lack  of  nutrition  by 
cutting  off  of  the  blood-supply,  forming  trophic  ulcer. 

Gangrene 

Gangrene  is  necrosis  or  death  en  masse  of  soft  tissue. 
It  is  caused  by  interference  with  the  blood-supply  of 
the  part  affected,  and  may  be  due  to  virulent  microbic 
infection.  It  is  also  seen  in  disorders  of  nutrition,  in 
which  the  arterial  supply  is  gradually  shut  off.  This 
variety,  known  as  dry  gangrene,  is  characterized  by  a 
shriveHng  up  of  the  part  affected,  which  turns  black  and 
finally  drops  off  if  not  previously  removed  by  the  sur- 
geon. In  moist  gangrene  there  is  also  obstruction  to 
the  veins;  the  part  becomes  swollen  by  distention  of  the 
tissues  with  exudation  from  the  vessels,  putrefaction 
sets  in,  giving  rise  to  a  very  foul  odor,  and  the  patient 
may  die  from  absorption  of  the  products  of  putrefaction. 

Necrosis 

The  term  necrosis  means  death  en  masse  of  any  tissue, 
but  is  usually  applied  to  death  of  bone.  It  is  pro- 
duced in  the  same  way  as  gangrene  of  the  soft  tissues, 
by  any  agent  that  destroys  its  blood-supply,  either 
through  the  internal  portion  of  the  bone  or  the  perios- 
teum covering  the  bone.     It  may  thus  follow  trauma, 


I06  ORAL  SURGERY 

chemic  action,  as  seen  in  poisoning  of  various  kinds, 
and  microbic  invasion  of  the  bone-marrow  (osteomyel- 
itis), or  of  the  periosteum  (periostitis). 

By  caries  of  bone  is  meant  a  slow  molecular  disinteg- 
ration of  the  bone. 


Bacteria    Commonly    Associated    with   Surgical 
Affections 

In  the  following  brief  account  only  the  more  important 
of  the  micro-organisms  will  be  mentioned,  and  there  will 
be  no  consideration  of  the  purely  bacteriologic  side  of 
the  subject,  which  can  be  obtained  in  text-books. 

The  commonest  organisms  met  with  are  the  pyo- 
genic cocci.  These  include  the  staphylococcus  aureus, 
staphylococcus  albus,  staphylococcus  citreus,  and  the 
streptococcus  pyogenes. 

The  staphylococcus  aureus  is  associated  with  practic- 
ally all  circumscribed  local  suppurations,  such  as 
abscesses,  boils,  etc. 

The  staphylococcus  albus  is  present  normally  in  the 
skin,  and  is  found  in  suppurative  lesions  of  the  skin, 
such  as  acne.  This  organism  is  responsible  for  stitch 
abscesses  after  operations. 

The  staphylococcus  citreus  is  less  common  than  the 
foregoing. 

The  streptococcus  pyogenes  is  the  commonest  cause 
of  spreading  infections,  cellulitis,  erysipelas,  etc.  It  is 
more  liable  to  cause  systemic  disturbance  than  the 
staphylococci,  resulting  in  grave  septicemia. 


INFLAMMA  TION  1 0/ 

Other  organisms  capable  of  producing  pus  under 
favorable  conditions  are  the  gonococcus,  pneumococcus, 
bacillus  typhosus,  bacillus  coli  communis,  bacillus 
pyocyaneus. 

The  gonococcus  is  the  specific  cause  of  gonorrhea.  In 
addition  to  infection  of  the  urethra,  it  may  cause  in- 
fection of  the  conjunctiva,  lymphatic  glands,  joints, 
and  serous  membranes. 

The  pneumococcus  is  at  times  responsible  for  suppu- 
rative lesions  of  joints  and  other  tissues. 

The  typhoid  bacillus  may  cause  suppuration  of  joints, 
glands,  and  other  tissues.  Abscess  of  the  parotid  gland 
is  a  frequent  sequel  of  typhoid  fever. 

The  colon  bacillus  is  frequently  responsible  for  in- 
fections connected  with  the  alimentary  and  genito- 
urinary tracts. 

The  bacillus  pyocyaneus,  or  green-pus  bacillus,  often 
becomes  ingrafted  on  another  infection,  particularly 
in  connection  with  the  alimentary  canal. 

The  bacillus  tuberculosis  is  of  surgical  interest  by 
reason  of  the  lesions  it  causes  in  bones,  joints,  and 
lymphatic  glands. 

The  bacillus  mallei  is  the  cause  of  glanders. 

The  bacillus  anthracis  is  the  cause  of  anthrax  or 
malignant  pustule,  a  disease  seen  in  wool-sorters  or  men 
engaged  in  the  handling  of  hides. 

The  tetanus  bacillus  is  the  cause  of  tetanus  or  lock-jaw. 
It  is  especially  found  in  soil,  dust,  and  in  sweepings  of 
stables.  The  organism  is  anaerobic,  and,  therefore,  deep 
or  punctured  wounds  are  more  liable  to  become  infected 
by  it  than  open  ones. 


I08  ORAL   SURGERY 

The  spirochetcB  pallida,  or,  more  correctly,  the  trep- 
onema  paHidum,  is  the  cause  of  syphilis. 

The  actinomyces,  or  ray-fungus,  is  the  cause  of  actino- 
mycosis. 

The  diphtheria  bacillus  is  occasionally  associated  with 
surgical  conditions. 

The  bacillus  aerogenes  capsulatus  is  found  in  cases  of 
emphysematous  gangrene. 

Review  Questions 

Define  inflammation. 

Give  tiie  etiology  of  inflammation. 

Describe  the  tissue  changes  taking  place  in  acute  inflammation. 

What  may  be  the  terminations  of  inflammation? 

Define  the  terms  stasis,  diapedesis,  phagocytosis,  abscess,  sinus, 
fistula. 

Give  the  five  cardinal  symptoms  of  inflammation,  with  the  explana- 
tion of  each. 

What  other  symptoms  may  be  present  in  inflammation? 

What  are  the  principles  of  treatment  of  inflammation? 

Explain  the  terms  cellulitis,  ulcer,  gangrene,  necrosis. 

Name  and  describe  briefly  the  principal  micro-organisms  associated 
with  surgical  affections. 


CHAPTER  XI 

CONTUSIONS  AND  WOUNDS 

Contusions 

A  contusion  is  an  injury  to  an  organ  or  to  the  sub- 
cutaneous tissues,  due  to  a  blunt  force,  in  which  the 
surface  remains  intact,  such  as  falls,  kicks,  blows,  etc. 

Pathology.— The  tissue  structure  is  torn,  blood-vessels 
are  ruptured,  and  there  is  an  effusion  of  blood  and 
lymph.  If  a  large  vessel  is  ruptured,  there  may  be 
a  considerable  extravasation  of  blood  into  the  tissues 
(ecchymosis),  or  there  may  be  a  distinct  cavity  in  the 
tissue,  containing  a  collection  of  blood  {hematoma). 
This  is  usually  gradually  absorbed,  but  may  undergo 
suppuration.  A  petechia  is  a  small  ecchymosis.  As 
blood  is  absorbed  it  undergoes  chemic  changes,  giving 
rise  to  a  succession  of  colors,  the  part  being  first  red, 
then  in  turn  purple,  black,  green,  and  yellow. 

Symptoms  of  contusion  are  swelling,  pain,  tenderness, 
and  numbness.  Swelling,  due  to  rupture  of  a  blood- 
vessel, appears  very  quickly  after  the  injury,  while 
later  swelling  is  due  to  the  exudation  of  lymph.  Dis- 
coloration of  the  skin  appears  early  in  superficial  con- 
tusions, late  in  deep  ones.  A  hematoma  fluctuates  at 
first,  later  becomes  hard,  due  to  coagulation  of  the  blood. 
Secondary  softening  is  usually  due  to  suppuration,  and 
is  accompanied  by  the  symptoms  of  inflammation. 

109 


no  ORAL   SURGERY 

Treatment. — This  in  most  cases  consists  in  rest,  com- 
pression, and  application  of  cold  to  the  part.  If  the 
swelling  increases,  due  to  rupture  of  a  large  vessel,  an 
incision  must  be  made,  and  the  vessel  sought  for  and 
ligated.  The  only  other  indications  for  incision  are 
persistence  of  the  swelUng  for  some  weeks,  infection, 

and  gangrene. 

"Wounds 

A  wound  is  an  injury  involving  a  breach  in  the  surface. 

Wounds  are  divided  into  incised,  lacerated,  contused, 
and  punctured. 

An  incised  wound  is  a  clean  cut,  made  by  a  sharp- 
edged  instrument,  with  loss  of  only  a  thin  film  of 
tissue. 

A  lacerated  wound  is  one  in  which  the  tissues  and  skin- 
edges  are  torn,  made  by  a  dull  instrument. 

A  contused  wound  is  one  in  which  the  tissues  are 
crushed,  made  by  a  blunt  instrument. 

A  -punctured  wound  is  one  of  varying  depth,  made  by 
a  pointed  instrument. 

When  it  communicates  with  a  cavity,  it  is  known  as  a 
■penetrating  wound. 

Gunshot  wounds  may  be  lacerated,  contused,  punc- 
tured, or  penetrating.  Any  of  these  varieties  may  be 
complicated  by  the  presence  of  bacteria,  resulting  in 
an  injected  wound. 

Hemorrhage  is  a  symptom  of  all  wounds.  Fain  is, 
as  a  rule,  not  so  severe  after  incised  wounds  as  after 
other  varieties. 

In  an  incised  wound  the  skin-edges  gape  less  if  the  cut 
be  parallel  to  the  fibers  of  the  underlying  muscle.  If 
the  muscle-fibers  be  cut  across,  the  edges  usually  gape 


CONTUSIONS  AND    WOUNDS  III 

widely,  resulting  in  a  broader  scar,  and  also  in  greater 
functional  disturbance  after  healing  has  taken  place. 
This  point  should  be  borne  in  mind  in  making  incisions 
at  operations. 

General  Principles  of  Treatment  of  Wounds. — i. 
Arrest  hemorrhage.  2.  Remove  foreign  bodies.  3. 
Render  aseptic.  4.  Drain,  and  bring  edges  together. 
5.  Secure  rest. 

1.  Any  but  the  smallest  bleeding  vessels  are  grasped 
with  hemostatic  forceps  and  secured  by  ligatures. 
Capillary  oozing  may  be  controlled  by  hot  applications 
or  by  compression.  Bleeding  from  small  vessels  in  the 
skin  is  often  arrested  by  the  sutures  which  bring  the 
edges  together, 

2.  All  visible  foreign  bodies,  such  as  bits  of  glass, 
clothing,  etc.,  should  be  removed  with  forceps.  Devit- 
alized tissue  should  be  trimmed  away. 

3.  To  thoroughly  cleanse  a  wound,  shave  any  hair 
from  the  immediately  surrounding  skin,  wash  the  skin 
with  tincture  of  green  soap,  followed  by  alcohol  and 
5  per  cent,  solution  of  iodin.  Any  wound  other  than  that 
made  by  the  surgeon  should  be  swabbed  out  with  the 
last  solution.  If  dirt  be  ground  into  a  wound,  wash  first 
with  turpentine,  followed  by  soap  and  germicidal  solution. 

4.  In  superficial  wounds,  suture  the  edges  together 
without  drainage.  Deep  wounds  require  drainage  by 
strands  of  silkworm-gut,  catgut,  rubber  tubing,  or  gauze. 
Bring  together  divided  muscle-fibers  or  tendons  with 
deep  sutures  of  chn^micized  catgut.  Bring  the  skin- 
edges  together  with  interrupted  sutures  of  catgut,  silk- 
worm-gut, or  horsehair,  leaving  space  for  the  drain.  In- 
fected wounds  must  invariably  be  drained.  Arrange  the 
drainage  material  loosely,  so  that  it  will  not  dam  back 


112  ORAL   SURGERY 

the  fluid.  Strips  of  rubber  dam  may  be  used  to  drain 
small  wounds.  Drainage  should  be  employed  for  at  least 
twenty-four  hours.  After  that  time  the  appearance  of 
the  wound  is  a  guide  as  to  drainage.  Apply  a  wet 
dressing  of  gauze  saturated  with  equal  parts  of  i  :  looo 
bichlorid  solution  and  alcohol  over  all  infected  wounds, 
or  those  in  which  infection  is  suspected.  This  stimulates 
phagocytosis  and  feels  more  comfortable  than  a  dry 
dressing.  Cover  the  wet  dressing  with  waxed  paper  to 
retain  the  moisture  as  long  as  possible,  or  pour  on  fresh 
solution  from  time  to  time.  In  badly  infected  wounds 
it  is  well  to  arrange  to  keep  a  constant  drip  of  fresh 
bichlorid  solution,  i  :  10,000,  on  the  dressing,  by  means 
of  a  vessel  suspended  above  the  part  with  a  piece  of 
gauze  hanging  over  the  side.  An  infected  wound  is 
redressed  at  least  every  twenty-four  hours.  An  aseptic 
wound  should  be  inspected  in  two  days.  Skin  stitches 
may  be  removed  from  superficial  wounds  in  four  or 
five  days.  An  aseptic  wound  may  be  sealed  with  White- 
head's varnish  after  closure  with  a  continuous  suture. 
This  is  particularly  useful  in  parts  of  the  body  which 
are  liable  to  become  bathed  with  secretions,  such  as  the 
region  of  the  mouth.  It  is  made  up  as  follows:  Iodo- 
form, I  ounce;  compound  ethereal  solution  of  benzoin, 
5  ounces. 

5.  Rest.  Immobilize  the  parts  by  bandaging  and 
splints  if  necessary. 

In  punctured  wounds  where  there  is  a  possibility 
of  infection  by  the  tetanus  bacillus,  the  parts  are  cauter- 
ized with  pure  carbolic  acid,  followed  by  the  applica- 
tion of  alcohol,  and  a  prophylactic  dose  of  1500  units  of 
tetanus  antitoxin  should  be  administered  subcutan- 
eously. 


CONTUSIONS  AND    WOUNDS  II3 

Wounds  of  mucous  membranes  such  as  the  mouth  are 
always  infected,  but,  as  a  rule,  heal  remarkably  well. 
In  a  wound  of  the  mouth  the  hemorrhage  should  first  of 
all  be  arrested,  after  which  steps  should  be  taken  to 
reduce  the  amount  of  infection  as  much  as  possible. 
Deposits  of  decomposing  food  and  tartar  should  be  re- 
moved from  the  teeth,  all  useless  roots  extracted,  and 
carious  teeth  treated.  An  antiseptic  mouth- wash  should 
be  employed  at  frequent  intervals.  Small  wounds  of  the 
mouth  require  no  suture,  but  the  edges  of  large  lacerated 
or  incised  wounds  should  be  brought  together  with  cat- 
gut, which  does  not  have  to  be  removed,  or  horsehair, 
which  must  be  taken  out  after  four  or  five  days. 

If  made  by  the  surgeon  in  the  course  of  an  operation, 
under  approximately  aseptic  conditions,  small  incised 
wounds  of  the  mouth  may  be  closed  without  drainage, 
interrupted  horsehair  sutures  being  employed.  In  lacer- 
ated or  contused  wounds,  or  incisions  made  in  connection 
with  large  areas  of  infection,  the  raw  surfaces  should  be 
painted  with  tincture  of  iodin,  after  which  partial  closure 
may  be  made  with  catgut  or  horsehair,  but  an  opening 
should  be  left  for  drainage  with  a  strip  of  rubber  dam. 

Repair  of  Tissue 

After  a  wound,  there  is  an  exudation  of  lymph,  fibrin, 
and  white  blood-corpuscles.  The  corpuscles  become 
changed  into  fixed  connective-tissue  cells,  and  other 
connective-tissue  cells  are  formed  by  proliferation  from 
surrounding  tissues.  From  the  walls  of  neighboring 
capillaries  plugs  of  endothelial  cells,  known  as  fibro- 
blasts, are  thrown  out,  which  unite  with  similar  out- 
growths from  the  opposite  side  of  the  wound.     These 

R 


114  ORAL   SURGERY 

plugs  are  at  first  solid,  but  later  become  hollowed  out, 
forming  new  capillaries.  The  connective-tissue  cells 
elongate  until  they  take  on  the  character  of  white 
fibrous  tissue.  This  reparative  tissue  is  known  as  granu- 
lation tissue.  In  incised  wounds  whose  edges  have  been 
brought  together,  healing  by  primary  union  or  first 
intention  takes  place.  This  means  that,  as  there  is 
no  loss  of  substance  to  be  made  up,  only  a  thin  layer  of 
granulation  tissue  is  formed  between  the  two  sides  of 
the  wound,  leaving  a  linear  scar. 

In  larger  wounds,  where  a  considerable  amount  of 
tissue  has  been  lost,  healing  takes  place  by  second  in- 
tention. Here  the  space  between  the  edges  of  the  wound 
is  filled  in  with  granulation  tissue,  and  proHferation  of 
epithelium  from  the  edges  gradually  covers  over  the 
surface: 

What  is  known  as  healing  by  third  intention  is  some- 
times brought  about  by  approximation  of  two  granu- 
lating surfaces. 

Repair  of  soft  tissues  after  inflammation  takes  place 
in  the  same  way  as  after  wounds. 

In  the  case  of  bones,  the  lost  tissue  is  replaced  by 
fibrous  connective  tissue  into  which  lime  salts  are  de- 
posited by  the  osteoblasts,  forming  new  bone. 

Review  Questions 

What  is  a  contusion?     Give  its  symptoms  and  treatment. 
Define  the  terms  ecchymosis,  petechia,  hematoma. 
Define  the  term  wound.     Give  the  varieties,  symptoms,  and  general 
principles  of  treatment  of  wounds. 

Describe  healing  by  first  and  second  intention. 
How  are  bones  repaired? 


CHAPTER  XII 


SURGICAL  FEVER 


Aseptic  surgical  fever,  first  described  by  Billroth,  is 
the  almost  invariable  sequel  of  a  surgical  operation  or 
severe  injury,  in  the  absence  of  infection,  and  is  believed 
to  be  due  to  the  absorption  of  fibrin  ferment  from  the 
seat  of  injury.  There  is  no  evidence  of  infection  of  the 
wound,  and  the  patient  feels  well.  There  is  an  eleva- 
tion of  temperature,  sometimes  to  103°  F.,  beginning 
on  the  evening  of  the  operation,  and  lasting  for  twenty- 
four  or  forty-eight  hours. 

Aseptic  surgical  fever  requires  no  treatment.  The 
symptoms  of  septicemia  should  be  carefully  watched  for, 
and  the  bowels  opened  with  a  purge.  The  wound  should 
not  be  disturbed. 

Septic  Surgical  Fever 

Under  this  general  heading  are  included  three  condi- 
tions due  to  the  entrance  into  the  system  of  micro- 
organisms or  their  products  through  a  wound  or  breach  of 
surface. 

1.  Sapremia  is  a  constitutional  disorder  due  to  chemic 
poisoning  by  the  products  of  bacteria,  these  products 
having  been  absorbed  from  the  wound.  It  is  usually 
the  result  of  putrefaction. 

2.  Septicemia  is  a  disorder  caused  by  the  action  of 
the  products  of  living  micro-organisms  that  have  gained 

115 


Il6  ORAL   SURGERY 

entrance  into  the  body,  and  are  undergoing  growth  and 
multiplication  there.  It  differs  from  sapremia  in  that 
the  poison  is  being  continually  produced  within  the 
body,  while  in  sapremia  the  poison  is  produced  in  the 
wound,  that  is,  outside  the  body. 

3.  Pyemia  is  a  disease  produced  by  the  absorption 
of  pyogenic  organisms  into  the  blood,  and  character- 
ized, in  addition  to  other  symptoms,  by  the  formation 
of  abscesses  in  various  tissues  of  the  body. 

Sapremia 

This  is  usually  seen  in  connection  with  a  putrefying 
mass  of  material  in  a  wound,  such  as  a  blood-clot.  A 
common  cause  of  sapremia  is  retention  of  blood-clot 
and  fetal  membranes  in  the  uterus  after  delivery. 

Symptoms. — These  usually  come  on  suddenly  and 
early  in  the  case.  The  temperature  rises  to  103°  or 
104°  F.,  and  is  sometimes  associated  with  a  rigor.  The 
skin  is  flushed,  hot,  and  dry,  and  the  patient  complains 
of  headache  and  thirst.  The  tongue  is  coated  and 
persistent  vomiting  may  occur.  The  pulse  is  rapid  and 
full,  the  respirations  hurried.  Inspection  of  the  wound 
reveals  a  foul-smelling  discharge. 

The  diagnosis  from  septicemia  depends  chiefly  on 
rapid  recovery  after  removal  of  the  putrefying  material. 

Prognosis. — Very  favorable  if  the  cause  is  removed 
early. 

Treatment. — Clean  out  the  putrefying  blood-clot 
or  other  material,  taking  care  to  injure  the  surrounding 
parts  as  Httle  as  possible.  Do  not  use  strong  germicidal 
solutions.  In  severe  cases  stimulation  may  be  advisable 
in  the  form  of  alcohol,  such  as  whisky,  half  an  ounce 


SURGICAL   FEVER 


117 


every  four  hours  by  mouth,  or  strychnin  hypodermic- 
ally.  Subcutaneous  infusion  of  normal  saline  solution, 
half  a  pint  every  three  hours,  dilutes  the  poison  in  the 
blood.  Persistent  vomiting  is  best  treated  by  washing 
out  the  stomach.  The  diet,  while  marked  symptoms 
persist,  should  be  hquid,  in  the  form  of  milk  or  albumin 

water. 

Septicemia 

The  organisms  usually  associated  with  this  disease 
are  the  pyogenic  cocci,  which  are  absorbed  from  a  wound 
into  the  surrounding  tissues  or  into  the  blood,  where 
they  grow  and  liberate  their  toxins. 

Symptoms. — As  in  sapremia,  these  come  on  early. 
There  is  a  rapid  rise  of  temperature  to  103°  or  105°  F., 
which  remains  high  and  is  usually  associated  with 
rigors.  The  pulse  is  rapid,  and  in  severe  cases  may  be 
weak  and  irregular.  Respiration  is  rapid  and  there  may 
be  dyspnea  or  cyanosis.  Vomiting  is  not  so  marked 
as  in  sapremia.  Headache  and,  later,  delirium  are 
usually  present.  Examination  of  the  blood  shows 
leukocytosis.  Locally,  the  tissues  surrounding  the 
wound  (which  may  be  a  very  small  one)  become  swollen, 
reddened,  and  tender,  showing  the  signs  of  inflammation, 
and  later  there  may  be  suppuration.  The  neighboring 
lymphatic  glands  are  enlarged  and  tender  and  may 
suppurate. 

Prognosis. — This  is  very  grave.  The  disease  is  often 
fatal  and  recovery  is  generally  very  slow. 

Treatment. — The  wound  should  be  thoroughly  cleaned 
out  and  cauterized  with  pure  carbolic  acid  if  possible. 
The  same  general  treatment  is  indicated  as  in  sapremia, 
but   must   be   given   more   vigorously,   and   continued 


Il8  ORAL   SURGERY 

for  a  longer  time.  Tincture  of  the  chlorid  of  iron  in 
doses  of  15  minims  four  times  a  day  is  especially  effica- 
cious in  septicemia.  If  the  micro-organism  causing 
the  disease  can  be  isolated,  an  antitoxin  may  be  given. 

Pyemia 

The  micro-organism  usually  present  in  pyemia  is  the 
streptococcus  pyogenes,  though  the  micrococcus  aureus 
has  also  been  known  to  cause  it.  The  constitutional 
effects  are  due  to  the  action  of  the  toxins  of  these  bacteria 
in  the  blood-stream.  The  secondary  abscesses  are 
formed  by  the  micrococci  becoming  lodged  in  the  walls 
of  the  veins  (suppurative  phlebitis)  and  septic  thrombi 
becoming  detached  from  these,  and  being  carried  to 
various  organs.  Pyemia  is  frequently  a  sequel  of  acute 
suppurative  osteomyelitis.  A  case  of  osteomyelitis 
of  the  mandible,  for  instance,  may  be  followed  by  pyemia, 
with  secondary  foci  in  the  lungs,  peritoneum,  brain, 
and  joints. 

Symptoms. — Pyemia  does  not,  as  a  rule,  begin  as 
early  as  the  other  two  forms  of  surgical  fever.  Local 
signs  of  inflammation  appear  in  the  wound,  associated 
with  phlebitis  of  the  veins  of  the  region  under  the  red 
and  tender  skin.  The  general  symptoms  begin  with  a 
chill  and  rapid  rise  of  the  temperature  to  104°  or  105°  F. 
This  is  followed  by  profuse  sweating  and  a  fall  of  the 
temperature  two  or  three  degrees.  The  chills,  fever, 
and  sweats  occur  irregularly  throughout  the  course 
of  the  disease.  The  other  general  symptoms  resemble 
those  of  septicemia,  but  are  more  severe.  The  second- 
ary abscesses  appear  from  the  sixth  to  the  tenth  day,  and 
may  be  located  in  the  lungs,  spleen,  kidneys,  brain, 


SURGICAL    FEVER 


119 


peritoneum,  and  joints,  giving  rise  to  special  symptoms 
according  to  the  organ  affected. 

Prognosis. — Recovery  from  pyemia  is  extremely 
rare. 

Treatment. — The  wound  or  primary  seat  of  the  infec- 
tion must  be  thoroughly  cleaned  and  drained.  Cold 
sponging  may  control  the  fever.  Tincture  of  the  chlorid 
of  iron  and  quinin  should  be  given,  and  the  patient 
should  be  stimulated  as  in  septicemia.  Morphin  may 
be  required  to  relieve  pain.  Secondary  abscesses,  if 
accessible,  must  be  opened  and  drained. 

Review  Questions 

Define  surgical  fever,  and  give  its  varieties. 

Give  the  symptoms  and  differential  diagnosis  of  sapremia,  septi- 
cemia, and  pyemia. 

Give  the  prognosis  and  treatment  of  each. 


CHAPTER   XIII 

SYNCOPE,  SHOCK,  COLLAPSE 

Shock  is  that  state  of  prostration  which  may  follow 
any  excessive  disturbance  of  the  nervous  mechanism, 
as  in  those  who  have  been  severely  injured,  or  whose 
minds  have  been  shaken  by  intense  emotion  (Brodie). 

Collapse  is  a  condition  similar  to  shock,  differing  in 
its  mode  of  causation  and  rate  of  onset.  The  main 
symptoms  are  the  same. 

Syncope  J  or  fainting,  is  a  mild  degree  of  shock,  produced 
by  a  temporary  anemia  of  the  brain.  It  is  of  sudden 
onset  and  short  duration.  The  face  suddenly  becomes 
blanched,  the  pulse  small  and  rapid,  and  the  individual 
sinks  to  the  ground  unconscious  for  a  few  moments. 

Etiology. — Shock  is  usually  caused  by  severe  bodily 
injury,  following  operation,  or  associated  with  intense 
pain  or  emotional  disturbance.  It  sometimes  follows 
prolonged  anesthesia. 

Collapse  is  caused  by  severe  external  or  internal 
hemorrhage  and  loss  of  body  fluid,  as  through  persistent 
vomiting  or  diarrhea. 

Pathology. — Shock  is  due  to  a  depression  of  function 
of  cerebral  nerve-centers,  particularly  of  the  vasomotor 
centers,  resulting  in  dilatation  of  the  splanchnic  area 
and  a  lowering  of  blood-pressure. 

Collapse  is  brought  about  by  a  primary  loss  of  body 
fluid,  resulting  in  cerebral  anemia  and  consequent  de- 

120 


SYNCOPE,    SHOCK,    COLLAPSE  12 1 

pression  of  the  higher  nerve-centers,  with  lowering  of 
blood-pressure. 

Symptoms.— 5//ocA^  usually  comes  on  suddenly.  The 
skin  is  pale,  cold,  and  moist.  The  muscles  are  relaxed. 
The  patient  is  apparently  unconscious,  but  can  be  aroused 
and  will  reply  to  questions.  The  temperature  is  sub- 
normal, the  pulse  weak  and  rapid,  and  the  respirations 
shallow.  The  pupils  are  dilated.  The  sensibiUty  is 
dulled. 

In  collapse  the  onset  is  gradual,  and  the  symptoms, 
which  are  the  same  as  those  of  shock,  grow  progressively 
worse. 

Treatment.— 5y«co/?e.— Loosen  the  clothing  about 
the  neck,  place  the  patient  in  a  recumbent  position, 
or  thrust  the  head  down  between  the  knees,  douche  the 
head  with  cold  water,  and  allow  the  patient  to  inhale 
aromatic  spirits  of  ammonia.  As  the  patient  recovers 
consciousness  administer  one  dram  of  aromatic  spirits 
of  ammonia  in  a  little  water  by  the  mouth. 

Shock. --Kamove  the  exciting  cause  if  it  is  still  present, 
and  then  restore  the  circulatory  function.  Place  the 
patient  in  the  recumbent  position,  elevating  the  foot  of 
the  bed  to  assist  the  return  of  blood  from  the  lower 
extremities.  This  is  often  aided  by  bandaging  the 
lower  extremities.  Administration  of  saline  solution 
increases  the  volume  of  circulating  blood.  Where  a 
rapid  effect  is  desired,  from  one  to  two  pints  of  normal 
saline  solution  (a  teaspoonful  of  common  salt  to  a  pint 
of  sterile  water),  at  a  temperature  of  104°  to  112°  F., 
may  be  injected  directly  into  a  vein.  In  less  urgent 
cases  the  saline  solution  may  be  given  through  the 
rectum    fenteroclysis)   or  subcutaneously   (hypodermo- 


122  ORAL   SURGERY 

clysis).  To  prevent  loss  of  body  heat  the  patient  is 
wrapped  in  hot  blankets,  surrounded  by  hot- water 
bottles.  A  pint  of  hot  coffee  may  be  given  by  the 
rectum.  Where  the  shock  is  due  to  pain,  give  morphin, 
\  grain,  with  sulphate  of  atropin,  -^^-^  grain  hypodermic- 
ally,  and  repeat  if  necessary.  Other  valuable  stimu- 
lants are  aromatic  spirits  of  ammonia,  30  minims, 
camphor  in  olive  oil  (camphor,  i  grain,  olive  oil,  5  min- 
ims) in  15-minimdoses,  strychnin,  215"  grain,  atropin,  y^o" 
grain,  administered  hjrpodermically,  and  repeated  every 
three  hours  if  necessary.  The  most  rapid  effects  are 
produced  by  the  camphorated  oil  and  the  ammonia. 
AdrenaUn  chlorid  is  recommended  by  some,  but  its 
effects  are  only  transitory. 

CriWs  Method. — In  cases  of  sudden  heart  failure 
during  anesthesia  or  following  injury  Crile  injects 
normal  saline  solution  containing  adrenalin  directly 
into  the  common  carotid  artery  toward  the  heart,  com- 
bining this  with  massage  of  the  heart.  The  abdomen  is 
opened  through  the  left  rectus,  and  the  heart  massaged 
through  the  diaphragm.  Cases  have  been  literally 
brought  back  to  life  by  this  method. 

In  collapse,  caused  primarily  by  loss  of  body  fluids, 
the  administration  of  saline  solution  by  the  mouth  or 
by  injection  is  especially  valuable,  though  the  general 
principles  of  treatment  are  the  same  as  for  shock. 

Hemorrhage 

Hemorrhage  is  the  escape  of  blood  from  the  blood- 
vessels. It  may  be  either  spontaneous  or  due  to  trau- 
matism. The  blood  may  either  escape  from  the  surface 
of  the  body,  or  into  the  tissues  surrounding  the  blood- 


HEMORRHA  GE  1 2  3 

vessels,  when  it  is  known  as  extravasation.  A  circum- 
scribed collection  of  extravasated  blood  is  known  as  a 
hematoma.  A  hemorrhage  is  known  as  internal  when  it 
escapes  into  one  of  the  body  cavities,  such  as  the  peri- 
toneal cavity,  but  is  not  met  with  in  the  region  of  the 
body  with  which  we  have  to  deal. 

There  are  three  anatomic  varieties  of  hemorrhage — 
arterial,  venous,  and  capillary. 

1.  Arterial  hemorrhage  is  caused  by  section  or  rupture 
of  an  artery.  There  is  a  flow  of  bright-red  blood,  which 
occurs  in  spurts  coincident  with  the  heart-beat. 

2.  Venous  hemorrhage  is  caused  by  injury  to  a  vein. 
There  is  a  continuous  flow  of  dark  colored  blood. 

3.  Capillary  hemorrhage  is  characterized  by  a  steady 
oozing  of  blood  from  a  wound. 

The  clinical  varieties  of  hemorrhage  are  primary, 
intermediate,  and  secondary. 

1.  Primary  hemorrhage  occurs  immediately  after  the 
division  of  a  blood-vessel. 

2.  Intermediate  hemorrhage  occurs  after  the  reaction 
from  shock,  due  to  disturbance  of  the  temporary  blood- 
clot  by  increased  vigor  of  the  circulation.  It  occurs 
within  twenty-four  hours  after  the  injury. 

3.  Secondary  hemorrhage  occurs  after  the  first  twenty- 
four  hours.  It  may  be  due  to  sloughing  of  the  end  of 
the  vessel,  traumatism,  or  infection.  Certain  condi- 
tions predispose  to  it,  such  as  arteriosclerosis  and  hemo- 
philia. 

Certain  terms  are  also  used  in  connection  with  hemor- 
rhage from  particular  regions.  Thus,  epistaxis  refers  to 
nose-bleed;  hemoptysis,  the  coughing  up  of  blood; 
hematemesis,  the  vomiting  of  blood;  hematuria,  blood  in 
the  urine. 


124  ORAL    SURGERY 

Constitutional  Effects  of  Hemorrhage. — When  a  con- 
siderable amount  of  blood  has  been  lost,  the  pulse 
becomes  rapid  and  feeble,  the  respirations  gasping. 
There  is  a  sense  of  suffocation  or  air  hunger  and  intense 
thirst.  The  skin  is  cold,  pale,  and  moist.  Delirium 
may  be  present. 

Spontaneous  Arrest  of  Hemorrhage. — When  an  artery 
is  divided,  the  inner  and  middle  coats  curl  up  within 
the  lumen  and  occlude  the  cut  end.  The  blood  clots 
above  this  in  the  case  of  a  small  vessel  and  hemorrhage 
ceases  spontaneously.  The  escaped  blood  also  clots 
around  the  cut  end  of  the  vessel.  Later  the  clot  becomes 
converted  into  fibrous  tissue  by  the  process  of  repair. 

Methods  of  .Arresting  Hemorrhage. — Arterial  hemor- 
rhage is  arrested  by  grasping  the  bleeding  artery  with  a 
pair  of  hemostatic  forceps.  In  the  case  of  a  small 
artery  the  crushing  together  of  the  coats  of  the  vessel 
by  the  forceps  is  often  sufficient  to  stop  the  bleeding 
if  the  forceps  are  allowed  to  remain  for  a  few  minutes. 
Before  removing  the  forceps  the  vessel  may  be  twisted 
with  them.  In  the  case  of  larger  arteries  a  catgut  Hga- 
ture  is  tied  around  the  vessel  before  removing  the  for- 
ceps. Sometimes  it  is  necessary  to  tie  both  ends  of  the 
cut  vessel. 

Venous  Hemorrhage. — Bleeding  from  large  veins  is 
arrested  in  the  same  way  as  arterial  hemorrhage.  Mod- 
erate and  slight  venous  oozing  can  generally  be  controlled 
by  gauze  packing  or  compression.  Bleeding  from  a  small 
incised  wound  is  generally  stopped  after  the  skin  sutures 
are  tied,  if  they  are  placed  deeply  enough  to  compress 
the  bleeding  points. 

Capillary  hemorrhage  may  be  checked  by  the  applica- 


HEMORRHA  GE  1 2  5 

tion  of  hot  water  to  the  wound,  followed  by  compression 
with  gauze. 

Hemorrhage  Following  Tooth  Extraction. — Considering 
the  large  number  of  teeth  extracted,  this  is  not  a  very  fre- 
quent complication,  but  it  may  be  a  very  serious  and  even 
fatal  one.  If  undue  hemorrhage  occurs,  the  alveolus  is 
to  be  syringed  out  with  warm  water  to  dislodge  any  clots. 
In  most  cases  a  little  tannic  acid  on  cotton  packed  into 
the  socket  will  usually  stop  the  bleeding.  If  this  does 
not  sufhcc,  the  socket  should  be  tightly  packed  with 
gauze  covered  with  tannic  acid.  A  pad  of  gauze  is 
now  laid  over  the  plug,  and  the  teeth  of  the  two  jaws 
are  brought  together.  The  jaws  are  held  together  with 
Barton's  bandage.  In  most  cases  the  packing  should 
not  be  disturbed  for  twenty-four  hours.  The  gauze 
packing  in  the  tooth  socket  may  be  held  in  place  by  a 
crossed  ligature  passed  over  the  socket  and  secured  to 
teeth  on  either  side  of  it.  Sometimes  it  is  advisable  to 
replace  the  extracted  tooth  in  the  alveolus  and  allow  it 
to  remain  for  several  hours.  In  severe  cases  it  may 
become  necessary  to  ligate  the  external  carotid  artery. 

Persistent  capillary  hemorrhage  is  frequently  due  to 
a  deficiency  of  substances  which  bring  about  coagulation 
of  the  blood.  These  substances  may  be  supplied  to  a 
patient  in  whom  bleeding  from  a  tooth  socket  persists 
by  the  injection  hypodermically  of  normal  blood-serum. 
Normal  horse-serum  may  be  obtained  in  convenient 
syringes  for  this  purpose,  and  is  given  in  doses  of  lo  to 
20  c.c,  which  may  be  repeated  in  twenty-four  hours  or 
less  if  necessary.  Where  the  normal  horse-serum  is 
unobtainable  in  emergencies,  diphtheria  antitoxin  may 
be  used.    Normal  serum  has  also  been  successfully  em- 


126  ORAL   HEMORRHAGE 

ployed  locally  to  check  hemorrhage,  and  may  be  used 
on  the  cotton  packing  in  the  tooth  socket  instead  of 
tannic  acid. 

Constitutional  Treatment  Following  Hemorrhage. — 
The  patient  is  to  be  placed  in  the  recumbent  position, 
with  the  head  lowered,  and  kept  perfectly  quiet.  This 
is  secured,  if  necessary,  with  a  hypodermic  injection  of 
\  grain  of  morphin.  The  lost  blood  is  replaced  with 
intravenous  injection  of  one  to  two  pints  of  normal 
salt  solution,  and  circulatory  stimulation  is  carried  out 
by  hypodermic  injections  of  strychnin,  atropin,  and 
camphorated  oil,  in  the  doses  given  in  the  treatment  of 
shock.  If  the  site  of  the  hemorrhage  is  not  absolutely 
secured  from  further  bleeding,  judgment  must  be  exer- 
cised in  stimulating  the  circulation  on  account  of  the 
danger  of  setting  up  fresh  hemorrhage  from  increased 
arterial  pressure.  The  thirst  present  in  these  cases  is 
relieved  by  water,  either  by  the  mouth  or  by  the  bowel. 
The  anemia  following  severe  hemorrhage  is  to  be  treated 
later  by  tonics,  particularly  iron. 

In  some  cases  the  only  hope  of  improvement  is  by 
direct  transfusion  of  blood  from  another  person,  pre- 
ferably a  blood  relation  of  the  patient. 

Hemophilia 

Hemophilia  (hemorrhagic  diathesis)  is  a  congenital 
tendency  to  spontaneous  hemorrhage  and  immoderate 
hemorrhage  after  injury.  The  disease  is  restricted  to 
the  male  sex,  and  is  usually  hereditary  in  character, 
being  nearly  always  transmitted  through  the  female  sex. 

Etiology  and  Pathology. — The  blood  in  these  cases  is 
found  to  have  a  subnormal  number  of  leukocytes,  par- 


HEMOPHILIA  1 27 

ticularly  of  the  polymorphonuclear  leukocytes.  It  is 
now  recognized  that  the  disease  is  due  to  a  defect  in  the 
coagulating  power  of  the  blood. 

Symptoms. — The  diathesis  shows  itself  in  subcutaneous 
hemorrhages,  hemorrhage  into  joints,  and  immoderate 
spontaneous  bleeding  from  mucous  membranes,  for 
example,  from  the  nose  and  gums.  Moreover,  severe 
bleeding  follows  the  slightest  injury,  and  can  be  arrested 
only  with  great  difficulty.  Death  has  frequently  fol- 
lowed extraction  of  a  tooth  in  one  of  these  cases,  and 
as  extensive  dental  caries  is  very  often  associated  with 
hemophilia,  this  becomes  a  serious  complication.  There 
is  a  noticeable  tendency  for  the  hemorrhage  to  come  on 
at  night.  It  may  not  be  severe  immediately  after  in- 
fliction of  the  wound,  but  will  break  out  again  after  the 
patient  goes  to  sleep. 

Prognosis. — This  is  especially  unfavorable  in  infancy, 
but  the  coagulability  of  the  blood  increases  as  age 
advances,  and  while  the  outlook  is  never  good  so  far 
as  the  traumatic  hemorrhages  are  concerned,  yet  the 
patient,  as  he  grows  older,  becomes  careful  not  to  incur 
these,  and  the  tendency  to  spontaneous  hemorrhage 
usually  is  overcome. 

Treatment. — From  the  surgical  standpoint  the  chief 
consideration  is  the  prevention  and  arrest  of  traumatic 
and  postoperative  hemorrhage.  The  following  measures 
are  on  the  lines  laid  down  by  Sir  A.  E.  Wright. 

Prophylaxis.  In  a  patient  known  to  be  a  bleeder  it 
is  well  to  avoid  performing  any  operations,  if  possible. 
If  an  operation,  such  as  extraction  of  a  tooth,  becomes 
imperative,  some  attempt  may  be  made  to  increase  the 
coagulability   of   the   blood   by   the   administration   of 


128  ORAL   SURGERY 

drugs  by  the  mouth.  The  defect  in  nucleo-albumin  may 
be  supplied  by  the  administration  of  extract  of  thymus 
gland,  in  doses  of  5  grains  three  times  a  day.  The 
remedies  used  to  increase  coagulability  are  the  salts 
of  calcium  and  magnesium.  A  mixture  of  calcium 
chlorid  or  lactate  and  magnesium  carbonate  may  be 
given  in  doses  of  5  grains  of  each  three  times  a  day. 
These  measures  should  be  carried  out  for  several  days 
preceding  the  operation. 

If,  in  spite  of  these  precautions,  or  if  bleeding  occurs 
in  an  unsuspected  case  of  hemophilia,  the  remedies 
must  be  given  in  larger  doses — 20  grains  three  times  a 
day  of  the  thymus  extract  may  be  given.  An  initial 
dose  of  I  dram  of  calcium  chlorid  or  lactate,  or  a  mixture 
of  equal  parts  of  calcium  chlorid  and  magnesium  carbon- 
ate, may  be  given  to  an  adult,  followed  by  30  grains 
daily  to  keep  up  the  effects. 

The  injection  of  normal  blood-serum  in  suitable  doses, 
repeated  if  necessary,  is  indicated  in  hemophilic  bleed- 
ing, as  well  as  a  prophylactic,  just  as  in  ordinary  capillary 
hemorrhage.  Direct  blood  transfusion  may  also  give  suc- 
cessful results. 

Local  Treatment. — This  consists  in  the  application 
of  physiologic  styptics,  which  exert  their  effect  by 
accelerating  the  coagulation  of  the  blood  on  the  bleeding 
surface.  Wright  finds  that  with  such  a  styptic  he  can 
arrest  hemorrhage  from  the  cut  femoral  artery  of  a  dog, 
provided  the  artery  be  compressed  for  a  minute  or  two 
to  allow  consoUdation  of  the  clot.  This  styptic  is  made 
from  the  thymus  gland  of  a  calf  or  lamb.  The  gland 
is  chopped  up  finely  and  placed  in  a  jar  with  normal  salt 
solution  in  the  proportion  of  one  part  of  gland  to  ten 


HEMOPHILTA  1 29 

parts  of  the  solution.  The  extract  is  filtered  off,  and  0.5 
per  cent,  of  calcium  chlorid  added  to  the  filtrate  with  i 
per  cent,  of  carboHc  acid.  The  wound  is  plugged  with 
cotton  or  Hnt  soaked  in  the  styptic. 

Review  Questions 

Define  shock,  collapse,  syncope. 

Give  the  etiology,  symptoms,  and  treatment  of  shock. 

Define  and  give  the  anatomic  and  clinical  varieties  of  hemorrhage. 

Give  the  constitutional  effects  or  symptoms  of  hemorrhage. 

How  is  spontaneous  arrest  of  hemorrhage  brought  about? 

Give  the  methods  for  controlling  arterial,  venous,  and  capillary 
hemorrhage,  respectively. 

Give  the  methods  of  arresting  hemorrhage  following  tooth  extraction. 

What  is  the  constitutional  treatment  of  hemorrhage? 

Define  hemophilia.  Give  its  etiology,  pathology,  symptoms,  prog- 
nosis, and  treatment. 


CHAPTER   XIV 


ANESTHESIA 


Three  methods  of  inducing  anesthesia  are  employed 
at  the  present  time  for  the  performance  of  surgical 
operations.  The  three  forms  are  spinal,  local,  and  general. 

Spinal  anesthesia,  so  successfully  employed  by  Jon- 
nesco,  of  Bucharest,  has  not  met  with  universal  favor 
in  this  country,  and  a  limited  number  of  surgeons 
employ  it  in  operations  on  the  lower  extremities  and  lower 
part  of  the  trunk.  The  anesthesia  is  induced  by  paral- 
yzing the  sensory  spinal  nerve-roots  by  injection  of  a 
solution  of  stovain  into  the  spinal  canal  in  the  lumbar 
region.  This  method  is  not,  as  a  rule,  applicable  to 
operations  on  the  head  and  neck,  so  it  is  only  briefly 
mentioned  in  passing. 

Local  Anesthesia. — By  this  is  meant  the  induction  of 
loss  of  sensibility  in  a  part  by  the  local  application  or 
injection  of  certain  drugs.  Superficial  local  anesthesia 
may  be  induced  by  the  application  of  a  volatile  fluid, 
such  as  ethyl  chlorid.  This  is  applied  in  the  form  of  a 
spray,  and  by  its  evaporation  abstracts  heat  from  the 
part.  The  ethyl  chlorid  spray  is  suitable  for  opening 
small  abscesses.  Various  substances  are  used  to  paralyze 
sensory  nerve-endings  by  injection  into  the  skin.  Cocain 
hydrochlorid,  beta-eucain  hydrochlorid,  and  novocain 
are  the  most  commonly  used,  in  solutions  ranging  from 
I  to  5  per  cent.     Novocain  is  just  as  efficient  as  cocain, 

130 


ANESTHESIA  I3I 

and  is  practically  never  followed  by  toxic  effects.  More- 
over, the  novocain  solution  can  be  sterilized  by  boiling, 
which  is  not  true  of  cocain  without  interference  with  its 
anesthetic  properties.  For  most  practical  purposes  a 
I  per  cent,  novocain  solution  will  answer.  With  this  is 
combined  adrenalin  chlorid  in  the  proportion  of  i  part 
in  10,000.  The  adrenalin  enhances  the  anesthetic 
effect,  constricts  the  blood-vessels  of  the  part,  thus  less- 
ening hemorrhage,  and  retards  absorption  of  the  anes- 
thetic. This  form  of  local  anesthesia  is  applicable 
for  the  removal  of  small  growths  from  the  skin,  foregin 
bodies,  etc.  It  should  not  be  used  where  there  is  in- 
fection, and  extreme  care  should  be  employed  in  thorough 
sterilization  of  the  needle  and  the  parts  to  be  operated 
upon.  The  needle  is  introduced  into,  not  beneath,  the 
skin,  at  one  end  of  the  prospective  incision,  and  a  drop 
of  the  solution  injected.  The  needle  is  then  pushed  a 
little  further  along  the  hne  of  incision  and  another  drop 
injected.  This  is  continued  until  the  whole  line  of  inci- 
sion is  infiltrated  by  the  anesthetic.  Before  proceeding 
with  the  operation,  it  is  well  to  wait  two  or  three  min- 
utes for  the  anesthetic  to  take  effect. 

Local  Anesthesia  Jor  Extraction  of  Teeth  and  Operations 
About  the  Jaw  Bones. — With  improvements  in  technic 
and  the  substitution  of  novocain  for  cocain,  what  was 
formerly  condemned  as  dangerous  and  unsatisfactory, 
has  in  the  last  few  years  come  to  be  regarded  as  one  of  the 
most  valuable  aids  in  dental  and  oral  surgery.  The  essen- 
tials of  success  in  the  employment  of  local  anesthetics  are 
a  thorough  knowledge  of  the  anatomy  of  the  parts,  proper 
technic,  the  selection  of  suitable  cases,  and,  above  all,  the 
observance  of  absolute  asepsis.    It  is  dangerous  to  inject 


132  ORAL   SURGERY 

a  local  anesthetic  into  acutely  inflamed  tissues  about  a 
tooth,  as  the  introduction  of  any  fluid  under  pressure  in 
these  circumstances  may  result  in  spreading  the  infection 
or  sloughing  of  the  tissues.  The  anesthetic  effect,  too, 
is  not  nearly  so  powerful  when  the  tissues  are  inflamed. 
Again,  certain  people  of  nervous  temperament  are  not 
suitable  subjects  for  local  anesthesia,  their  nervous  con- 
dition causing  them  to  flinch  at  the  sight  of  instruments, 
the  prick  of  the  needle,  etc.  This  apphes  also  to  young 
children,  in  whom  general  anesthesia  is  more  satisfactory. 
For  details  of  the  technic  of  injection,  etc.,  the  reader  is 
referred  to  special  works  on  this  subject,  such  as  those  of 
Fisher-Riethmuller,  Thoma,  and  Allen. 

General  Anesthesia. — General  anesthesia  is  the  arti- 
ficial production  of  loss  of  consciousness  by  the  action 
following  inhalation  of  certain  drugs  upon  the  sensory 
nerve-centers  in  the  brain.  In  a  general  way  the  cranial 
nerves  are  affected  by  general  anesthetics  in  their  regular 
order,  beginning  with  the  olfactory. 

The  general  anesthetics  in  common  use  are  ether, 
chloroform,  and  nitrous  oxid.  Ethyl  chlorid  is  occasion- 
ally used. 

The  choice  of  an  anesthetic  depends  upon  several 
factors,  such  as  the  length  of  anesthesia  required,  the 
nature  of  the  operation,  and  the  condition  of  the  patient. 

For  prolonged  anesthesia,  ether  and  chloroform  are 
used.  For  the  vast  majority  of  cases  ether  should  be 
selected,  as  it  is  very  much  less  dangerous  than  chloro- 
form. The  number  of  deaths  following  the  inhalation 
of  chloroform  is  about  i  in  4000,  while  the  number  from 
ether  is  about  i  in  16,000.  Chloroform  is  more  danger- 
ous than  ether  because  it  acts  more  strongly  and  quickly 


ANESTHESIA  1 33 

upon  the  circulation  and  respiration  than  ether.     In 
its  administration  there  is  a  progressive  fall  of  blood- 
pressure.     The    comparative    infrequency,    too,    with 
which  chloroform  is  given  by  anesthetists  in  this  country 
undoubtedly  contributes  to  the  danger.     Chloroform  is 
much  more  pleasant  to  take  than  ether,  produces  less 
excitement,  less  irritation  of  the  respiratory  passages,  its 
effects  are  much  more  quickly  produced  than  those^  of 
ether,  while  there  is  usually  less  nausea  and  vomiting 
following    its    administration.     All    these    advantages, 
however,  are  counterbalanced  by  the  danger  of  chloro- 
form and  the  comparative  safety  of  ether,  and  there  are 
only  a  few  cases  in  which  the  latter  is  not  to  be  preferred. 
In  chronic  bronchitis,  asthma,  and  phthisis  pulmonalis, 
chloroform  is  preferable  to  ether,  as  the  latter  is  a  power- 
ful irritant  to  the  respiratory  passages.     In  case  of  war, 
chloroform  is  less  bulky,  and  the  patients  can  be  anes- 
thetized much  more  rapidly,  and  thus  there  is  the  possi- 
biUty  of  attending  to  a  greater  number  of  wounded. 
The  secondary  effects  of  chloroform  on  the  tissues  are 
more  serious  than  those  of  ether. 

Ether  is  said  to  be  unsatisfactory  in  tropical  countries, 
owing  to  its  great  volatility,  but  it  is  used  here  with 
success  in  the  hottest  weather.  It  is  also  said  that 
ether  is  less  suitable  for  children  than  chloroform,  but 
practical  experience  shows  that  it  can  be  employed  just 
as  satisfactorily  in  the  case  of  children  as  of  adults. 

Ether  Narcosis 
Ether  anesthesia  may  be  divided  into  four  stages,  as 
follows : 

I.  Stage  of  primary  anesthesia. 


134  ORAL  SURGERY 

2.  Stage  of  excitement. 

3.  Stage  of  relaxation. 

4.  Stage  of  collapse. 

First  Stage. — On  first  inhalation  of  ether  there  are 
burning  in  the  throat  and  a  feeling  of  strangulation,  due 
to  local  irritation  of  the  ether.  In  a  short  time  sensi- 
bility becomes  distinctly  lessened,  and  the  patient 
becomes  semiunconscious.  In  this  stage  minor  opera- 
tions, such  as  extraction  of  a  tooth  or  opening  an  abscess, 
can  be  performed  without  pain. 

Second  Stage. — The  first  stage  is  soon  succeeded  by 
the  stage  of  excitement.  The  patient  becomes  delirious 
and  often  violent.  The  muscles  are  rigid;  the  respira- 
tions are  rapid,  though  they  may  cease  through  spasm  of 
the  glottis;  the  face  is  flushed  and  moist.  Reflexes  are 
present  and  may  be  exaggerated.  The  pulse  is  rapid 
and  full.  The  pupils  are  dilated. 

Third  Stage. — In  this  stage  the  patient  becomes 
quiet.  The  muscles  are  relaxed;  the  corneal  and  other 
reflexes  are  lost.  The  pupil  is  contracted.  The  breath- 
ing is  slow,  deep,  and  regular.  The  pulse  is  full,  strong, 
and  slow.  The  skin  is  flushed,  warm,  and  moist.  This 
is  the  stage  during  which  surgical  operations  are  per- 
formed. Production  of  complete  surgical  anesthesia 
requires,  as  a  rule,  from  ten  to  fifteen  minutes. 

Fourth  Stage. — If  anesthesia  be  carried  beyond  the 
third  stage,  the  patient's  life  is  in  danger  from  collapse. 
The  breathing  becomes  stertorous  from  paralysis  of  the 
muscles  of  the  palate.  The  respirations  then  become 
shallow  and  irregular,  or  may  cease  altogether.  The 
pupil  dilates,  and  will  not  respond  to  light.  The  pulse 
becomes  rapid  and  weak.     The  skin  is  cold,  moist,  and 


ANESTHESIA  1 35 

dusky.  Ether  usually  produces  death  by  asphyxia, 
due  to  depression  of  the  respiratory  centers,  but  may  also 
act  fatally  by  depressing  the  heart.  On  the  nervous 
system  ether  acts  as  a  depressant,  first  on  the  cerebrum, 
then  the  sensory  side,  and  finally  the  motor  side,  of  the 
spinal  cord.  The  first  action  of  ether  upon  the  circula- 
tion is  as  a  stimulant  to  the  heart  and  vasomotor  centers, 
but  it  finally  depresses  the  heart  and  vascular  system. 

Extraction  of  a  tooth,  or  opening  of  an  abscess,  can 
often  be  performed  during  the  first  stage  of  ether  anes- 
thesia. In  these  cases  little  or  no  previous  preparation 
of  the  patient  is  necessary,  and  they  can  be  done  with 
the  patient  in  the  sitting  posture.  The  best  way  of  giving 
the  ether  in  these  cases  is  by  means  of  a  towel  folded  into 
the  shape  of  a  cone,  in  which  a  sponge  moistened  with 
warm  water  is  inserted.  A  considerable  quantity  of 
ether  is  poured  on  the  sponge,  and  the  face  of  the  patient 
gradually  approached  with  the  cone.  The  patient  is 
instructed  to  take  full  breaths  and  to  hold  up  one  arm. 
In  a  few  minutes  the  arm  drops  and  the  tooth  is  extracted 
without  pain. 

Before  the  administration  of  ether  for  complete 
anesthesia,  the  following  precautions  are  to  be  taken: 

No  food  should  be  taken  by  the  patient  for  at  least 
ten  or  twelve  hours  before  the  administration  of  the  ether 
where  a  long  operation  is  to  be  performed.  If  this 
precaution  be  not  observed,  vomiting  is  Hable  to  occur, 
with  danger  of  suffocation  and  aspiration  pneumonia. 
The  bowels  should  be  emptied  by  a  dose  of  magnesium 
sulphate  the  evening  before  the  operation.  The  patient's 
heart  and  lungs  should  be  carefully  examined.  It  is 
important  to  know  the  condition  of  the  kidneys,  both  as 


136  ORAL   SURGERY 

to  presence  in  the  urine  of  albumin  and  casts  and  the 
quantity  excreted.  Ether  is  a  powerful  irritant  to  the 
kidneys,  and  the  minimum  amount  must  be  used  in  the 
presence  of  nephritis. 

Just  before  administration  of  the  anesthetic  all 
foreign  bodies,  such  as  removable  artificial  teeth,  should 
be  taken  from  the  mouth.  The  clothing  about  the  neck 
and  chest  must  be  loosened.  The  horizontal  position 
is  preferred  in  administration  of  the  anesthetic,  but  the 
patient  can  later  be  placed  in  any  more  convenient 
position  for  the  performance  of  the  operation.  In 
giving  the  anesthetic  it  is  not  necessary  to  remove  the 
pillow  from  beneath  the  patient's  head,  as  is  so  often 
done.  Respiration  is  usually  much  less  embarrassed 
with  the  pillow.  The  lips  and  nostrils  of  the  patient 
should  be  anointed  with  vaseHn  before  giving  the  ether. 
Some  anesthetists  precede  the  administration  of  ether 
by  nitrous  oxid,  and  by  this  means  shorten  the  induction 
of  complete  anesthesia.  The  method  is  undoubtedly 
also  more  agreeable  to  the  patient,  and  the  after-effects 
are  said  to  be  less  noticeable.  But  in  the  experience  of 
the  writer,  for  prolonged  operations,  where  complete 
relaxation  is  necessary,  it  is  best  to  commence  with 
ether.  Patients  throughout  the  operation  do  not  seem 
to  lose  the  cyanosing  effects  of  the  nitrous  oxid,  thus 
masking  possible  cyanosis  from  the  ether,  and  complete 
relaxation  is  not  so  easily  attained.  If  the  ether  be 
given  slowly,  it  is  seldom  objected  to  by  the  patient. 
I  have  seen  one  anesthesia  death  following  the  combina- 
nation  of  nitrous  oxid  and  ether,  probably  caused  by 
mistaking  the  results  of  too  much  ether  for  nitrous  oxid 
cyanosis. 


ANESTHESIA 


137 


The  best  way  of  administering  the  ether  is  with  the 
ordinary  wire  mask  (Fig.  26)  usually  employed  in 
giving  chloroform.  It  is  easily  handled  and  removed 
when  necessary  in  operations  about  the  face,  and  has  the 
especial  advantage  that  plenty  of  air  is  admitted  with 
the  ether.  This  latter  is  the  most  important  point  in 
ether  administration.  About  four  layers  of  gauze  are 
placed  on  the  mask  and  a  few  drops  of  ether  allowed  to 
fall  on  them.  The  mask  is 
held  at  first  at  some  little 
distance  from  the  patient's 
face,  and  gradually  made  to 
come  nearer,  until  finally  the 
fumes  become  tolerable  and 
it  can  be  laid  directly  in 
contact  with  the  face.  After 
this  the  ether  can  be  given 
more  rapidly,  but  still  drop 
by  drop,  and,  if  necessary,  a 
few  more  layers  of  gauze  tem- 
porarily applied,  which  can 
be  removed  when  anesthesia 
is  complete.  By  this  open 
method,  with  slow  adminis- 
tration of  the  ether  and  allowing  admixture  of  plenty 
of  air,  a  longer  time  is  required  for  anesthesia  than 
by  giving  the  ether  in  larger  quantities  and  excluding 
the  air,  but  relaxation  becomes  more  complete,  and  the 
general  conditiun  of  the  patient  is  much  better  through- 
out the  operation.  The  patient  is  instructed  to  breathe 
deeply  and  regularly,  but  forcible  respiration  is  to 
be    avoided.      Any   cessation   of   the   respiration   dur- 


Fig.  26. — Wire  frame  for  hold- 
ing gauze  in  ether  anesthesia. 


138  ORAL  SURGERY 

ing  the  early  stages  is  due  to  local  irritation  or  spasm 
of  the  glottis.  A  full  breath  of  air,  followed  by  an  in- 
crease in  the  amount  of  the  anesthetic,  is  generally  suc- 
cessful in  restoring  natural  respiration.  The  lower  jaw 
should  be  kept  forward  by  pressure  of  the  fingers  behind 
the  angle.  This  prevents  the  tongue  from  falling  back 
and  obstructing  the  glottis.  During  the  stage  of  excite- 
ment the  patient  may  become  so  violent  as  to  require 
assistants  to  hold  him.  When  the  patient  is  quietly 
resting  upon  the  operating  table,  the  arms  should  be 
secured  to  the  sides  by  a  towel  passed  under  the  body,  the 
ends  being  fastened  to  the  wrists  with  safety-pins.  This 
prevents  the  arms  from  hanging  over  the  sides  of  the 
table,  and  consequent  risk  of  musculospiral  paralysis 
from  pressure  on  the  nerve  by  the  edge  of  the  table. 

The  indications  that  anesthesia  is  complete  are 
relaxation  of  the  muscles  and  absence  of  the  corneal 
reflex.  During  the  operation  the  anesthetist  must 
from  time  to  time  note  the  condition  of  the  pulse,  and 
report  it  to  the  operator.  The  pulsation  of  the  temporal 
artery  can  be  conveniently  felt  immediately  in  front  of 
the  ear.  He  should  remove  any  mucus  which  may 
have  collected  in  the  throat  by  means  of  a  gauze  sponge. 
Respiration  may  be  aided  by  inserting  a  mouth-gag, 
drawing  the  tongue  forward,  and  holding  it  with  a  small 
piece  of  gauze  in  the  fingers.  This  is  preferable  to  the 
tongue  forceps,  which  crush  and  wound  the  tongue  un- 
necessarily. During  the  operation  the  patient  is  kept 
under  with  the  minimum  amount  of  ether,  continually 
administered  drop  by  drop.  The  best  guide  to  the 
depth  of  anesthesia  is  the  respiration  of  the  patient. 
A  slight  break  in  the  regularity  of  the  breathing  is  an 


ANESTHESIA  1 39 

indication,  as  a  rule,  that  the  patient  is  coming  out,  and 
to  push  the  anesthetic  a  little.  During  deep  anesthesia 
the  pupil  is  contracted.  As  it  becomes  less  profound 
the  pupil  dilates,  but  will  respond  to  light.  When  the 
ether  is  pushed  too  far,  the  pupil  also  dilates,  but  does 
not  respond  to  light.  The  depressant  effects  of  the 
ether  also  show  themselves  in  a  duskiness  of  the  skin, 
due  to  sluggish  circulation.  This  is  well  seen  in  the  lobe 
of  the  ear.  Pressure  causes  the  cyanosis  to  disappear,  and 
it  returns  slowly  when  the  pressure  is  released.  Cyanosis 
is  accompanied  by  a  gradual  acceleration  in  the  pulse- 
rate  and  a  decrease  in  its  volume.  These  signs  call  for 
stimulation  and  a  termination  of  the  operation  in  as 
short  a  time  as  possible. 

Strychnin  sulphate,  -j\j  grain,  and  atropin  sulphate, 
yj^  grain,  and  tincture  of  digitalis,  lo  minims,  may  be 
given  hypodermically,  and  the  first  repeated  if  necessary. 
In  more  extreme  cases,  with  the  pulse  at  i6o  or  higher, 
especially  when  the  patient  has  lost  a  considerable 
quantity  of  blood,  intravenous  infusion  of  a  pint  or  more 
of  normal  saline  solution  is  indicated. 

Vomiting  during  the  operation  is  usually  a  sign  that  the 
anesthesia  is  not  sufficiently  deep.  Its  onset  is  heralded 
by  retching,  and  it  can  often  be  averted  by  pushing 
the  ether.  If  vomiting  does  occur,  remove  the  mask 
and  turn  the  head  of  the  patient  to  one  side  to  prevent 
inspiration  of  the  vomited  material.  As  soon  as  possible 
after  the  throat  has  been  cleared  the  administration  of 
the  anesthetic  is  continued. 

In  case  of  respiratory  failure,  remove  the  anesthetic 
at  once,  see  that  the  tongue  has  not  fallen  back  to  ob- 
struct  the  glottis,   and   attempt   to  set  up  respiratory 


140  ORAL   SURGERY 

movements  by  pressure  on  the  chest.  A  piece  of  gauze 
saturated  with  aromatic  spirits  of  ammonia  placed  over 
the  nostrils  will  often  be  of  assistance.  If  these  fail, 
regular  artificial  respiratory  movements  should  be  tried. 
Administration  of  oxygen  with  the  ether  in  all  cases  that 
show  a  tendency  to  respiratory  embarrassment  should 
be  a  regular  procedure. 

Sudden  heart  failure  calls  for  cardiac  massage  and 
Crile's  method  of  saline  infusion  into  the  carotid  artery 
(see  section  on  Shock). 

The  anesthetic  may  be  withdrawn  several  minutes,  as 
a  rule,  before  the  operation  is  completed,  and  may  be 
replaced  with  oxygen  or  aromatic  spirits  of  ammonia. 
Careful  watch  should  be  kept  over  the  patient  recovering 
from  the  anesthetic,  as  vomiting  almost  invariably 
occurs,  and  the  respiratory  passages  must  be  kept  clear 
of  vomited  material. 

Ether  vapor  is  heavier  than  air,  and  consequently 
the  fumes  during  its  administration  tend  to  settle  in  the 
lower  part  of  the  room.  As  ether  is  very  inflammable, 
all  gas,  candle,  or  lamp  lights  should  be  well  above  the 
level  of  the  patient.  The  thermocautery  should  not 
be  used  near  the  anesthetic.  The  fact  that  ether  vapor 
is  heavier  than  air  also  renders  anesthesia  most  rapid 
when  the  mask  is  held  vertically  above  the  face  of  the 
patient. 

For  operations  within  the  mouth  various  forms  of 
apparatus  have  been  devised  for  introducing  the  anes- 
thetic into  the  respiratory  passages  without  interrupting 
the  operation.  The  ether  may  be  given  in  the  form  of 
vapor  by  means  of  catheters  passed  into  the  pharynx 
through  the  nose,  or  directly  into  the  trachea  through 


ANESTHESIA  14I 

the  mouth  (intratracheal  insufflation).  In  all  these 
methods  the  ether  is  vaporized,  mixed  with  air,  and 
pumped  in  by  means  of  an  electric  motor,  a  foot 
bellows,  or  a  hand  bulb. 

Nitrous  Oxid 

For  short  operations,  such  as  the  extraction  of  teeth, 
opening  abscesses,  etc.,  nitrous  oxid  gas  (N2O)  is  a  suit- 
able anesthetic,  though  in  the  practice  of  the  writer  its 
use  has  become  considerably  replaced  by  local  anes- 
thetics.    It  is  best  given  combined  with  oxygen. 

Nitrous  oxid  has  the  following  advantages  over  other 
general  anesthetics: 

1.  It  is  the  safest  anesthetic  known. 

2.  It  requires  very  little  previous  preparation  of  the 
patient. 

3.  The  patient  can  be  anesthetized  either  in  a  recum- 
bent or  a  sitting  posture. 

4.  The  patient  is  rapidly  anesthetized. 

5.  Ill  after-effects  are  seldom  produced  by  nitrous 
oxid. 

The  disadvantages  of  nitrous  oxid  are: 

(i)  The  appliance  required  for  its  administration  is 
very  heavy  and  cumbersome. 

•  (2)  Its  effects  pass  off  very  rapidly,  and  it  is,  therefore, 
not  suitable  for  operations  in  the  mouth  that  require 
more  than  a  few  seconds. 

By  the  use  of  oxygen  with  the  nitrous  oxid  the  period 
of  anesthesia  can  be  lengthened,  though  the  effects 
pass  off  as  rapidly  as  with  nitrous  oxid  alone,  and  with 
the  introduction  of  the  nasal  inhaler  prolonged  opera- 
tions within  the  mouth  may  be  successfully  undertaken. 


142  ORAL   SURGERY 

The  writer,  however,  reserves  nitrous  oxid  and  oxygen 
for  cases  in  which  local  anesthesia  is  contraindicated 
and  unsuitable,  and  where  the  operation  is  not  of  suffi- 
cient consequence  to  require  hospital  facilities.  But  in 
operations  on  other  parts  of  the  body  the  combination  of 
oxygen  and  nitrous  oxid  is  very  useful  in  cases  where  other 
anesthetics,  such  as  ether  or  chloroform,  are  contra- 
indicated.  The  writer  has  had  experience  with  it  in 
operations  lasting  nearly  an  hour.  By  this  method  the 
cyanosis  induced  by  nitrous  oxid  alone  is  eliminated, 
and  after-effects  are  more  rarely  seen.  Perfect  relax- 
ation of  the  muscles  can  be  obtained.  The  time  re- 
quired to  anesthetize  a  patient  by  this  method  is  rather 
longer  than  by  nitrous  oxid  alone.  The  operator  must 
judge  of  the  amount  of  oxygen  required  by  watching  the 
face  of  the  patient  for  cyanosis.  The  amount  of  oxygen 
used  ranges  from  4  to  lo  per  cent. 

Before  administering  nitrous  oxid,  the  clothing  about 
the  neck  of  the  patient  should  be  loosened,  and  removable 
artificial  teeth  or  other  foreign  bodies  taken  from  the 
mouth.  A  cork  or  rubber  prop  should  be  placed  between 
the  teeth  on  the  side  opposite  to  that  upon  which  the 
operation  is  to  be  performed.  The  patient  is  instructed  to 
take  slow  full  breaths,  and  is  made  to  go  through  several 
respirations  of  this  character  with  the  hood  over  the  face 
and  the  air- valve  open.  When  proper  breathing  has 
been  established,  the  gas  is  turned  on  and  air  excluded. 
The  time  for  anesthesia  to  become  complete  varies, 
but  averages  about  a  minute  and  a  half.  The  indica- 
tions of  the  onset  of  the  anesthesia  are  a  tremor  or 
shaking  of  the  body,  stertorous  breathing,  and  cyanosis. 
The  tremor  generally  appears  first,  followed  by  cyanosis 


ANESTHESIA  1 43 

and  stertorous  breathing.  Stertorous  breathing  is  the 
surest  sign  of  complete  anesthesia,  and  calls  for  with- 
drawal of  the  anesthetic.  The  operator  usually  in- 
structs the  patient  to  hold  up  one  arm,  and  as  soon  as 
this  falls  to  the  side,  anesthesia  is  regarded  as  complete. 
The  effects  last  about  a  minute  or  a  minute  an  a  half. 
After  this  period  has  passed  the  patient  gradually  regains 
consciousness,  the  return  often  being  accompanied  by 
laughing,  weeping,  and  sometimes  violence.  Conscious- 
ness returns  in  about  two  minutes,  after  which  no  ill 
effects  are  felt  by  the  patient,  as  a  rule.  The  anesthetic 
effect  of  nitrous  oxid  is  in  part  due  to  deprivation  of 
oxygen,  but  chiefly  to  the  inherent  action  of  the  gas  upon 
the  sensory  centers.  It  is  unsafe  to  continue  administra- 
tion of  the  gas  after  anesthesia  has  been  induced,  and 
it  is,  therefore,  not  available  for  prolonged  operations 
unless  combined  with  oxygen.  The  operator  must 
judge  of  the  amount  of  oxygen  required  by  watching  the 
face  of  the  patient.  He  can  start  anesthesia  with  pure 
nitrous  oxid,  and  then  add  oxygen,  gradually  increasing 
the  percentage  as  cyanosis  appears,  just  giving  enough 
to  eliminate  the  cyanosis,  and  yet  not  enough  to  coun- 
teract the  effect  of  the  nitrous  oxid. 

Ethyl  Chlorid 

Ethyl  chlorid,  under  the  names  of  somnoform,  nar- 
cotile,  etc.,  is  used  to  a  considerable  extent  for  the 
extraction  of  teeth  and  other  minor  operations.  It 
resembles  nitrous  oxid  in  the  rapidity  of  its  action  and 
fugaciousness,  but  several  deaths  have  been  reported 
from  its  use,  so  that  it  is  not  to  be  recommended  for 
ordinary  practice. 


144 


ORAL  SURGERY 


Tracheotomy 

This  procedure  consists  in  making  an  artificial  open- 
ing in  the  wall  of  the  trachea  to  enable  respiration  to 
be  carried  on  after  obstruction  of  the  larynx.  The 
indication  for  its  performance  is  occlusion  of  the  res- 
piratory tract  above  the  trachea  by  inflammation  (diph- 
theria, laryngitis,  tuberculosis,  etc.),  edema  of  the 
glottis,  tumors,  and  foreign  bodies. 


Fig.  27. — Cohen's  tracheotomy  tubes:  i,  Outside  tube  and  obturator;  2,  obtu- 
rator; 3,  inside  tube;  a,  cross-section  of  the  tube  (Fowler). 


The  operation  is  performed  as  follows:  The  shoulders 
are  raised  and  the  head  thrown  back  as  far  as  possible, 
which  gives  increased  room  for  the  operation,  brings  the 
trachea  near  the  surface,  and  puts  it  on  the  stretch, 
thus  making  it  less  mobile.  A  median  incision,  3  inches 
long,  is  made  from  the  cricoid  cartilage  downward.  The 
sternohyoid  muscles  are  pulled  to  either  side  with  re- 
tractors, exposing  the  isthmus  of  the  thyroid  gland, 
which  usually  lies  over  the  second,  third,  and  fourth 


ANESTHESIA  1 45 

rings  of  the  trachea.  Cutting  the  isthmus  should  be 
avoided  if  possible,  owing  to  its  vascularity.  The  open- 
ing in  the  trachea  is  made  preferably  above  the  isthmus, 
the  latter  being  pushed  down.  The  trachea  is  opened 
by  a  longitudinal  incision  large  enough  to  admit  the 
silver  tracheotomy  tube  (Fig.  27),  w^hich  is  then  inserted 
and  secured  in  place.  Hemorrhage  may  occur  from 
division  of  the  inferior  thyroid  veins,  which  should  be 
controlled  by  ligation. 

Ligation  of  Common  Carotid  Artery  and  External 
Carotid  Artery 

One  of  these  procedures  is  carried  out  as  a  prelimin- 
ary to  operations  on  the  head  and  neck  w'here  a  large 
portion  of  tissue  is  to  be  removed,  as  a  precaution  for 
the  control  of  hemorrhage,  for  example,  before  removal 
of  the  upper  jaw  for  sarcoma.  It  is  also  done  in  the 
treatment  of  aneurysm  of  one  of  these  arteries  and  for 
arresting  hemorrhage  which  cannot  be  stopped  by  the 
usual  methods.  The  common  carotid  artery  is  ligated 
in  the  superior  carotid  triangle,  just  before  its  bifurca- 
tion at  the  level  of  the  upper  border  of  the  thyroid 
cartilage.  An  incision  2  inches  long  is  made  over  the 
anterior  edge  of  the  sternocleidomastoid  muscle,  through 
the  skin,  superficial  fascia,  platysma  myoides,  and  deep 
fascia.  The  pulsation  of  the  artery  is  now  felt  for  and 
the  carotid  sheath  opened.  The  artery  lies  to  the  inner 
side  of  the  internal  jugular  vein,  with  the  pneumo- 
gastric  nerve  between  and  behind  the  vessels.  To 
avoid  wounding  the  vein,  the  ligature  Csilk)  is  passed 
by  means  of  an  aneurysm  needle  around  the  artery 
10 


146  01? AL    SURGERY 

from  the  outer  side,  care  also  being  taken  not  to  include 
the  pneumogastric  nerve  in  the  ligature.  If  the  artery 
is  to  be  severed,  it  must  be  tied  in  two  places  and  cut 
between  the  ligatures. 

The  external  carotid  artery  is  also  ligated  in  the  supe- 
rior carotid  triangle,  just  above  the  level  of  the  upper 
edge  of  the  thyroid  cartilage.  After  bifurcation  of  the 
common  carotid,  the  external  carotid  lies  at  first  nearer 
the  median  Hne  than  the  internal  carotid,  for  which  it 
must  not  be  mistaken.  The  branches  of  the  external 
carotid  artery  may  also  be  ligated  in  the  superior  carotid 
triangle. 

Review  Questions 

Define  local  anesthesia. 

Give  some  of  the  local  anesthetics  in  common  use,  with  indications  for 
and  mode  of  administration. 

What  are  the  dangers  of  the  hypodermic  use  of  cocain  as  a  local  anes- 
thetic in  the  region  of  the  jaws? 

Define  general  anesthesia. 

Name  the  three  commonest  general  anesthetics  in  their  order  of  safety 
of  administration. 

Discuss  the  points  to  be  considered  in  the  selection  of  ether  or  chloro- 
form as  a  general  anesthetic. 

Describe  the  stages  of  ether  narcosis. 

Give  the  preliminary  measures  to  be  carried  out  before  the  adminis- 
tration of  ether. 

Describe  the  method  of  inducing  primary  ether  anesthesia  for  the 
extraction  of  a  tooth. 

Describe  the  method  of  inducing  complete  ether  anesthesia. 

What  are  the  most  reliable  signs  that  anesthesia  is  complete? 

What  are  the  signs  that  the  patient  is  coming  out  of  the  anesthesia? 

What  are  the  signs  that  the  patient  is  getting  too  much  ether? 

What  treatment  is  called  for  when  the  depressant  effects  of  the  anes- 
thetic begin  to  show  themselves? 

What  is  the  treatment  of  respiratory  failure  during  ether  anesthesia? 

What  is  the  treatment  for  sudden  heart  failure  during  ether  anesthesia? 

Give  the  treatment  of  vomiting  during  ether  administration. 


ANESTHESIA  1 47 

Is  ether  vapor  heavier  or  lighter  than  air?  What  is  the  importance 
of  knowing  this? 

Give  the  advantages  and  disadvantages  of  nitrous  oxid  as  a  general 
anesthetic. 

Give  the  advantages  of  the  use  of  oxygen  in  conjunction  with  nitrous 
oxid  in  anesthesia. 

What  are  the  indications  for  the  performance  of  tracheotomy?  Des- 
cribe the  operation. 

What  are  the  indications  for  hgating  the  common  carotid  or  the 
external  carotid  artery?     Describe  the  operation. 


CHAPTER  XV 

PREPARATION  FOR  OPERATION 

Operations  about  the  face  and  jaws  should  be  per- 
formed under  as  aseptic  conditions  as  possible,  that  is, 
bacteria  should  be  removed  from  the  field  of  operation 
and  excluded  from  it  after  the  operation.  In  external 
operations  on  the  face  and  neck  this  can  be  successfully 
carried  out,  but  within  the  mouth  asepsis  is  impossible, 
though  even  here  a  satisfactory  degree  of  cleanliness 
can  be  approached  by  removing  diseased  roots,  tartar, 
etc.,  and  by  the  use  of  antiseptic  mouth- washes  before 
operation.  The  skin  is  prepared  by  washing  with  soap 
and  sterile  water,  followed  by  alcohol  and  a  i  :  2000 
solution  of  bichlorid  of  mercury.  A  piece  of  sterile 
gauze  is  now  applied,  and  nothing  allowed  to  touch  the 
part  until  time  for  the  operation.  At  this  time  the 
region  of  incision  may  be  painted  with  a  5  per  cent, 
solution  of  iodin,  which  destroys  any  bacteria  in  the 
deeper  layers  of  the  skin  which  may  have  escaped  the 
preliminary  cleansing.  The  hands  of  the  operator  and 
of  his  assistant,  and  of  any  one  else  who  is  to  handle 
instruments  or  dressings  that  will  touch  the  wound,  are 
sterilized  by  scrubbing  for  ten  minutes  with  soap  and 
water,  followed  by  alcohol  and  the  bichlorid  solution. 
The  surgeon  should  preferably  wear  sterile  rubber  gloves. 
It  is  hardly  necessary  to  add  that  the  instruments, 
dressings,  towels,  and,  in  fact,  everything  that  comes  in 
contact  with  the  wound  must  be  sterile.     For  opera- 

148 


PREPARATION  FOR    OPERATION 


149 


tions  within  the  mouth,  these  precautions  are  all  carried 
out,  except,  of  course,  that  the  mouth  cavity  cannot  be 
rendered  sterile.  Some  degree  of  asepsis,  however,  can 
be  attained  by  painting  the  mucous  membrane  in  the 
field  of  operation  with  tincture  of  iodin  just  before  mak- 
ing the  incision. 

Instruments  Commonly  Required  in  Operations 

Knives. — A  scalpel  (Fig.  28)  is  a  broad-bladed  knife 
for    making   incisions    through    the    skin    and    tissues. 


Fig.  28. — I,  Scalpel;  2,  bistoury  (Gibbon). 

A  bistoury  (Fig.  28)  is  a  narrow^  sharp-pointed  knife  for 
opening  abscesses  and  making  small  incisions. 


Fig.  2g. — A,  S(  issors  curvcJ  on  the  flat;  B,  straight  scissors;  C,  angular  scissors 
(Fowler). 

Scissors  (Fig.  29),  which  may  be  straight  or  curved,  are 
used  ior  cutting  tissue,  sutures,  ligatures.,  dressings,  etc. 


150  ORAL    SURGERY 

Dressing  forceps  are  used  to  grasp  the  tissue  while  dis- 
secting it  during  the  operation,  to  handle  dressings,  etc. 

Hemostatic  forceps  (Fig.  30)  are  instruments  used  to 
clamp  blood-vessels  to  arrest  hemorrhage. 


Fig.  30. — Hemostatic  forceps  (de  Nancrede). 

A  grooved  director  (Fig.  31)  is  a  long,  probe-like  instru- 
ment, which  is  grooved  on  one  side  to  act  as  a  guide  for 
the  knife-blade. 

Probes  are  usually  made  of  silver,  and  have  a  ball-like 
end,  which  permits  them  to  easily  follow  the  course  of 
sinuses  and  spaces  within  the  tissue. 


r. — Grooved  director  (Fowler). 


Allis'  forceps  (Fig.  32)  are  long  toothed  forceps  which 
can  be  clamped,  and  are  useful  as  retractors  and  for 
grasping  tissue  during  dissection. 

A  blunt  dissector  is  a  dull-bladed  instrument  used  in 
dissecting  tissues  without  cutting  them. 

An  osteotome  is  a  chisel-shaped  instrument  used  in 
conjunction  with  a  mallet  for  cutting  bone. 

Retractors  are  instruments  used   to  draw  back  the 


PREPARATION  FOR    OPE  RATIO  A' 


151 


skin  and  other  tissues  to  give  a  better  view  of  the  field 
of  operation. 


tig.  32. — Allis'  forceps  (GibbonJ. 


The  instruments  required  in  an  ordinary  operation 
are:   Knife,  scissors,  dressing  forceps,  several  pairs  of 


Fit;.  33. — Rack-anfl-pinion  mouth-Rag  (Fowler). 

hemostatic   forceps,   grooved   director,   j^robe,   and   re- 
tractors. 


152 


ORAL   SURGERY 


For  operations  within  the  mouth  a  mouth-mirror, 
mouth-gag  (Fig.  33),  and  tongue  depressor  (Fig.  34) 
are  required  in  addition  to  the  other  instruments.  In 
operations  on  the  jaw  bone  the  surgical  engine  and 
various  burs,  drills,  etc.,  are  required.  For  the  extrac- 
tion of  teeth  dental  forceps  (Fig.  35)  and  elevators  (Fig. 
36)  are  used. 


Fig.  34. — Bosworth's  tongue  depressor  (Keen's  Surgery). 


The  surgical  engine  designed  by  Cryer  (Fig.  37)  is 
indispensable  for  operations  about  the  jaws,  and  is  to 
be  preferred  to  the  chisel  and  mallet  in  general  bone 
surgery.  It  is  adaptable  for  trephining  and  osteoplastic 
operations  in  brain  surgery,  drilling  holes  in  the  operative 
treatment  of  fractures,  removal  of  bone  in  osteomyelitis, 
and,  in  fact,  for  all  the  uses  to  which  ordinary  bone 


PREPARATION  FOR    OPERATION 


153 


instruments  are  put.     The  engine  is  modeled  after  the 
cord  dental  engine,  but  is  larger,  and  the  hand-piece  and 


Fig.  35.— A,   Lower  molar  forceps;   B,   Universal  upper  forceps   (Cryer);   C, 
Universal  lower  forceps  (Cryer). 


Fig.  36. — No.  3  elevator. 


accessories  are  fitted  for  heavier  work  than  the  dental 
engine.     Saws,  trephines,  drills,  and  burs,  of  various 


154 


ORAL   SURGERY 


sizes  and  shapes,  may  be  obtained  to  fit  the  hand-piece. 
The  engine  may  be  driven  by  hand  or  by  an  electric 
motor. 


f^/sactuaZ.  size,) 


Fig-  37- — Cryer's  surgical  engine,  spiral  osteotome,  drill,  and  bur. 


The  spiral  osteotome  is  a  useful  instrument  used  for 
cutting  bone  with  the  surgical  engine.  For  brain 
surgery  it  is  furnished  with  a  special  guard,  to  protect 


PRE  PAR  A  TIOX  FOR    OPERA  TION  \  5  5 

the  dura  and  cerebrum  from  its  point.  With  this 
instrument  the  bone  cutting  necessary  for  an  osteoplastic 
flap  can  be  cut  in  the  skull  in  less  than  two  minutes. 

Ligatures.  Sutures,  Etc. 

A  ligature  is  a  thread  used  to  tie  around  a  blood-ves- 
sel after  the  latter  has  been  secured  with  hemostatic 
forceps,  and  also  to  tie  around  pedunculated  growths. 
Ligatures  are  nearly  always  composed  of  catgut  (No. 
I,  plain)  or  silk.  In  tying  ligatures  a  double  square  knot 
should  always  be  used.  In  the  case  of  a  large  vessel 
it  is  better  to  secure  this  with  a  third  knot. 

A  suture  is  a  thread  used  with  a  needle  to  close  a 
wound.  J\lany  materials  are  used  for  sutures,  the  com- 
monest being  catgut,  plain  and  chromicized,  silk, 
silkworm-gut,  horsehair,  and  silver  wire. 

Sutures  may  be  continuous,  a  single  thread  being 
used  to  close  the  wound  from  one  end  to  the  other,  or 
interrupted,  in  which  case  a  series  of  threads  is  used 
at  intervals. 

Catgut  is  absorbed  by  the  tissues,  and  sutures  of  this 
material  do  not  have  to  be  removed  by  the  surgeon. 
Plain  catgut  usually  is  absorbed  in  three  or  four  days, 
while  chromicized  catgut  remains  from  ten  to  twenty 
days.  All  other  suture  materials  are  non-absorbable. 
and,  therefore,  surface  sutures  of  these  require  removal. 
In  wounds  of  the  skin  of  the  face,  where  there  is  little 
tension,  sutures  of  fine  silk  or  horsehair  are  least  liable 
to  leave  a  scar.  Horsehair  is  also  the  least  irritating  in 
the  mucous  membrane  of  the  mouth,  and  does  not  swell 
from  absorption  of  fluid.  In  larger  wounds,  where  there 
is  considerable  tension,  interrupted  sutures  of  silkworm- 
gut  are  the  most  satisfactory. 


156  ORAL   SURGERY 

In  using  non-absorbable  material  it  is  better  to  make 
interrupted  sutures,  as  it  is  easier  and  less  painful  to 
remove  them,  especially  in  children.  Many  varieties 
of  needles  are  employed  for  inserting  sutures.  For  the 
skin  a  needle  with  a  cutting-edge  is  necessary.  When 
possible,  it  is  better  to  use  a  straight  needle  than  a  curved 
one,  as  this  does  away  with  the  necessity  for  a  needle- 
holder.  A  pair  of  hemostatic  forceps  makes  a  conveni- 
ent needle-holder,  but  in  time  this  spoils  it  for  any  other 
purpose.  Sutures  should  be  tied  firmly,  but  not  too 
tightly.  Undue  tension  causes  sloughing  of  the  tissue 
and  cutting  out  of  the  sutures.  The  edges  of  the  tissue 
should  be  approximated  and  not  made  to  overlap  or  fold 
in.  The  suture  is  tied  with  a  double  square  knot,  with 
the  exception  of  silkworm-gut,  which  may  be  tied  with 
a  single  surgeon's  knot.  Silver  wire  sutures  are  used  in 
some  cleft-palate  operations  to  hold  the  two  halves  of  the 
palate  in  apposition. 

Drainage  Materials 

Glass  and  rubber  tubing,  rubber  dam,  gauze,  and 
strands  of  catgut  or  silkworm-gut  are  used  among  other 
materials  for  this  purpose.  Glass  tubes  are  used  prac- 
tically only  after  abdominal  operations. 

Rubber  tubing  may  be  used  to  drain  abscess  cavities 
in  which  the  discharge  is  very  free.  Holes  should  be 
cut  in  the  rubber  tube  at  intervals.  It  may  be  sutured 
to  the  edge  of  the  wound  with  silkworm-gut  or  a  safety- 
pin  may  be  put  through  it  at  each  end  to  prevent  it 
from  slipping  out  of  the  wound. 

Strips  of  gauze  may  be  employed  for  drainage.  They 
should  be  packed  in  lightly,  and  drainage  is  considerably 


PREPARATION  FOR    OPERATION- 


'S? 


aided  by  previously  moistening  the  gauze.  It  is  not 
necessary  to  use  iodoform  gauze  about  the  face. 

Strips  of  rubber  dam  cut  with  serrated  edges  are  useful 
for  providing  drainage,  and  have  the  advantage  over  gauze 
that  that  they  do  not  become  clogged  with  secretions 
from  the  wound  and  act  as  plugs. 

Strands  of  catgut  and  silkworm-gut  are  sometimes 
tied  together  and  used  for  draining  superficial  wounds. 

Dressings  for  wounds  consist  of  pads  of  sterile  gauze, 
secured   in   place   by   means   of   adhesive   plaster   and 


I-'ig.  38.— Barton's  bandage  (Fowler). 

bandages.     Zinc  oxid  adhesive  plaster  should  always  be 
used  in  contact  with  the  skin. 

Bandages  are  made  of  muslin  or  of  gauze.     Gauze  is, 
as  a  rule,  satisfactory  for  holding  ordinary  dressings 


158  ORAL   SURGERY 

in  place,  but  where  considerable  support  and  firmness 
are  required,  as  in  the  case  of  fractures,  the  musHn 
bandage  is  preferable. 

The  Barton  bandage  (Fig.  38),  or  one  of  its  modi- 
fications, is  the  most  useful  about  the  head. 

For  this  bandage  muslin  or  gauze  2  inches  in  width  is 
used,  and  is  apphed  as  follows:  Starting  at  the  occiput, 
the  bandage  is  carried  to  the  vertex,  then  beneath  the 
chin,  to  the  vertex,  to  the  occiput,  around  the  jront  of 
the  chin,  ending  at  the  occiput.  These  turns  should  be 
repeated  three  times.  When  additional  stability  is 
required,  this  may  be  secured  by  ending  with  a  turn  or 
two  around  the  forehead.  The  direction  in  which  the 
turns  are  made  may  vary  with  the  individual  case. 
The  Barton  bandage  is  used  in  dressing  fractures  of  the 
jaws,  and  in  some  cases  alone  suffices  to  maintain  im- 
mobility. In  cases  of  fracture  of  the  angle  or  ramus  the 
turn  in  front  of  the  chin  would  tend  to  pull  the  jaw  too 
far  back.  A  modification  of  the  Barton  bandage  is 
used  in  these  cases,  the  bandage  passing  from  the  occiput 
to  the  vertex,  under  the  chin,  to  the  vertex,  to  the 
occiput,  under  the  chin,  to  the  vertex,  to  the  occiput, 
under  the  chin,  to  the  vertex,  ending  at  the  occiput. 
This  modification  is  also  useful  in  holding  dressings  to 
the  jaw  for  any  purpose. 

Review  Questions 

Describe  the  measures  for  sterilization  to  be  carried  out  before  per- 
forming an  operation. 

Define  the  following:  Grooved  director,  osteotome,  ligature,  suture. 
Give  the  suture  materials  in  common  use,  and  the  indications  for  each. 
Describe  the  Barton  bandage. 


Special  Surgery 


CHAPTER    XVI 

HYPERTROPHY 

By  the  term  hypertrophy  is  meant  an  overgrowth  of 
tissue  in  which  the  individual  cells  maintain  their 
normal  physiologic  functions.  The  overgrowth  may  be 
due  either  to  an  increase  in  the  size  of  the  individual 
cells,  or  to  an  increase  in  their  number  (hyperplasia), 
or  both.  The  term  hyperplasia  is  not  confined  to 
hypertrophic  conditions  alone,  but  is  applied  to  any 
increase  in  number  of  cellular  elements,  such  as  that  seen 
in  inflammatory  conditions  and  in  neoplasms. 

Hypertrophy  may  be  inherited  or  acquired. 

In  inherited  hypertrophy,  certain  portions  of  the 
body  may  be  the  seat  of  the  overgrowth,  e.  g.,  the  gums 
and  alveolar  process.  In  cases  of  this  kind  the  gum 
tissues  may  be  so  redundant  as  to  completely  hide  the 
teeth.  The  lips  bulge  out,  giving  the  patient  the 
appearance  of  a  receding  chin  (Figs.  39,  40). 

Acquired  h>^ertroph'y  may  be  the  result  of  increased 
demand  for  work  on  the  tissue,  mild  irritation  continued 
over  a  long  period  of  time,  overnutrition,  and  other 
factors.  Acquired  hypertrophy  of  the  gums  is  caused 
by  irritation  of  various  kinds.  A  badly  fitting  plate 
may  cause  the  gum  tissue  in  the  anterior  part  of  the 

159 


l6o  SPECIAL   SURGERY 

mouth  to  grow  down  between  the  plate  and  the  front 
of  the  bony  ridge,  giving  the  appearance  known  as 
''double  lip."  In  the  roof  of  the  mouth  a  deep  vacuum 
chamber  with  sharp  edges  will  often  cause  hypertrophy. 
A  badly  fitting  crown  or  clasp"  may  set  up  irritation  about 
the  neck  of  a  tooth,  thus  causing  hypertrophy  of  the 


Fig.  39. — From  photograph  of  a  lad  sufifering  from  hypertrophy  of  the  gums  and 
alveolar  process  (after  Cryer). 

gum.     In  the  same  way  a  cavity  in  a  tooth  often  becomes 
filled  with  hyper trophied  gum  tissue. 

Treatment. — In  inherited  hypertrophy  this  consists 
in  removal  of  the  excess  of  gum  tissue  by  operation. 
To  do  this  it  may  be  necessary  to  enlarge  the  opening 
of  the  lips  by  an  incision  on  the  face.  Where  the 
teeth  are  embedded  in  the  hypertrophied  tissue,  they 
often  have  to  be  removed.     When  the  parts  have  healed, 


//  yPER  TROPHY  1 6 1 

an  artificial  denture  may  be  put  in  to  replace  the  lost 
teeth. 

In  acquired  hypertrophy  of  the  gums  the  first  thing 
to  do  is  to  remove  the  cause,  whether  it  be  a  badly 
fitting  plate,  vacuum  chamber,  or  crown.  An  over- 
growth of  gum  tissue  in  a  tooth  cavity  may  be  removed 
after  cauterizing  with  trichloracetic  acid.     In  the  case 


Fig.  40. — Tissue  removed  from  upper  jaw  of  patient  shown  in  Fig.  39  (after 

Cryer). 

of  "double  lip"  under  local  anesthesia  the  hypertrophied 
tissue  can  be  cut  away  with  gum  scissors,  the  base  of  the 
growth  having  been  previously  ligated,  if  necessary,  to 
control  hemorrhage.  If  the  growth  is  pedunculated,  it 
can  be  ligated  and  cut  off.  Where  the  hypertrophy  is 
only  slight,  removal  of  the  cause  and  painting  the  parts 
with  astringents,  such  as  glycerol  of  tannic  acid,  will 
generally  be  sufficient  treatment. 


11 


l62  SPECIAL   SURGERY 


Neoplasms  or  Tumors 


A  neoplasm  or  tumor  is  a  new-growth  of  cells,  resemb- 
ling in  structure,  as  a  rule,  the  organ  or  tissue  from  which 
it  arises,  but  having  an  atypical  arrangement  of  cells 
and  no  useful  function. 

Etiology.— Certain  facts  are  known  as  to  the  etiology 
of  tumors,  but  we  are  still  in  the  dark,  to  large  extent, 
and  can  only  resort  to  theory — and  none  of  these 
theories  is  adequate  to  explain  all  tumors. 

Cohnhehn's  Theory. — According  to  this  theory,  cer- 
tain cells  which,  in  the  course  of  development,  have  been 
displaced  from  their  normal  relationship  or  have  failed 
to  grow  with  the  rest  of  the  body,  retain  their  embryonic 
properties,  and  later  on  in  life  take  on  renewed  growth, 
resulting  in  tumor  formation.  This  theory  can  be 
applied  in  part  to  certain  forms  of  tumors,  particularly 
teratomata  and  some  new-growths  of  malignant  type, 
but  cell  displacement  cannot  account  for  all  tumors. 

The  microhic  theory  might  suffice  to  explain  the  cause 
of  cancer,  but  not  of  other  tumors.  It  has  not  yet  been 
found  that  certain  micro-organisms  set  up  certain  forms 
of  new-growth. 

All  that  we  can  say  at  present  is  that  there  is  a  change 
in  the  biologic  properties  of  cells  giving  origin  to  tumors, 
and  can  only  theorize  on  what  brings  about  this  change. 
External  stimulus  may  favor  this  change,  and  it  is  well 
known  that  certain  forms  of  tumor  are  especially  apt 
to  follow  trauma  or  irritation,  but  this  factor  is  not 
essential. 

Heredity,  age,  and  sex  seem  to  act  as  predisposing 
factors  in  the  causation  of  certain  kinds  of  tumors. 


TUMORS 


163 


Classification. — Tumors,  as  a  rule,  are  classified  in 
accordance  with  their  resemblance  to  normal  tissues. 
Inasmuch  as  all  tissues  have  a  framework  of  connec- 
tive tissue  holding  the  cell^  proper  in  place,  tumors  of 
epithehal  type  are  not  composed  of  epithelial  tissue 
alone,  but  contain  connective  tissue  as  well,  though  the 
essential  nature  of  the  tumor  lies  in  the  epithelial  ele- 
ments. Three  great  types  of  tumors  are,  therefore, 
recognized,  according  to  the  tissues  from  which  they 
are  derived: 


I.  Epithelial  type. 


'  Papilloma  (warts). 
Adenoma  (glandular  tissue). 
Neuroma  (nerve  tissue). 
Carcinoma  (embryonic  epithelial  tissue). 
Epithelioma  (embryonic  squamous  celled 
epithelial   tissue.      Subvariety  of  car- 
cinoma). 
Fibroma  (fibrous  tissue), 
^lyoma  (muscular  tissue). 
Chondroma  (cartilaginous). 
Osteoma  (bony). 
Angioma  (vascular). 
Lymphoma  (lymphatic  tissue). 
Lymphangioma  (lymphatic  vessel  tissue). 
Myxoma  (mucous  connective  tissue). 
Lipoma  (fatty  tissue). 
Sarcoma  (embryonic  connective  tissue). 
Myeloma  (bone-marrow). 

IIL  Mixed  ty,.e,  composed   |  ^^^^^^^^  (j.^j^^id  cyst,  odontoma). 
of  both  tissues • 


IL  Connective-tissue  type. 


Two  varieties  may  be  combined,  giving  rise  to  com- 
pound tumors,  such  as  fibromyoma,  adenofibroma,  osteo- 
chondroma, angiofibroma,  osteosarcoma,  myelosarcoma, 
etc.  There  are  also  many  sub  varieties  of  the  different 
types. 


164  SPECIAL   SURGERY 

A  cyst  is  a  hollow  tumor,  usually  lined  with  epithe- 
lium, and  with  fluid  or  semifluid  contents. 

Clinical  Classification  of  Tumors. — Clinically,  tumors 
are  divided  into  two  types,  benign  and  malignant.  An 
intermediate  class  exists,  having  some  of  the  properties 
of  each. 

Benign  tumors  are  characterized  by  their  slow  growth, 
the  fact  that  they  are  usually  circumscribed  and  encap- 
sulated, do  not  have  a  deleterious  effect  on  the  organism 
at  large,  and  do  not  tend  to  recur  after  removal.  They 
closely  resemble  in  structure  the  adult  tissues  from  which 
they  spring,  and  do  not  infiltrate  surrounding  tissues. 

Malignant  tumors  are,  as  a  rule,  not  encapsulated  or 
circumscribed.  They  rapidly  infiltrate  the  surrounding 
tissues,  are  accompanied  by  pain,  have  a  deleterious 
effect  on  the  general  system,  tend  to  form  metastases 
in  other  parts  of  the  body,  and  tend  to  recur  after  re- 
moval. They  resemble  embryonic  tissue  in  their  struc- 
ture. Examples  of  this  type  are  carcinoma  and  sarcoma. 
Most  of  the  other  tumors  are  benign,  though  they  may 
cause  ill  effects  or  even  death  by  pressure  on  vital 
structures. 

To  the  intermediate  type  belong  certain  forms  of 
tumors  microscopically  malignant  that  infiltrate  sur- 
rounding tissues  very  slowly,  do  not  form  metastases, 
and  do  not  tend  to  recur  after  removal.  Benign  growths 
that  tend  to  undergo  malignant  change  may  also  be 
placed  in  this  group. 

Carcinomata,  which  are  composed  of  epithehal  cells 
of  embryonic  type  embedded  in  a  stroma  of  connective 
tissue,  are  divided  into — (i)  scirrhus,  or  hard  cancer,  and 
(2)  medullary,  encephaloid,  or  soft  cancer,  according 


TUMORS  165 

as  the  connective  tissue  or  the  epitheHal  tissue  prepon- 
derates. Thus  a  tumor  composed  of  much  connective- 
tissue  stroma  with  few  epithelial  cells  would  be  scirrhous, 
while  one  containing  many  epithelial  cells  and  but  Httle 
stroma  would  be  medullary.  Another  variety  of  car- 
cinoma, composed  of  flat  or  squamous  epithelium,  is 
known  as  epithelioma.  The  more  cells,  in  proportion 
to  the  connective  tissue,  the  more  malignant  the  tumor. 
Sarcomata  are  divided  into  several  varieties  according 
to  the  types  of  cells  of  which  they  are  composed.  Thus 
we  have  small  round-celled  sarcoma,  large  round-celled 
sarcoma,  spindle-celled  sarcoma,  giant-celled  sarcoma, 
etc.  The  smaller  the  cells,  as  a  rule,  the  more  malig- 
nant the  growth.  Thus,  small  round-celled  sarcoma  is 
very  malignant,  while  giant-celled  Sarcoma  has  compara- 
tively little  malignancy. 


DIFFERENTIAL  DIAGNOSIS   BETWEEN   CARCINOMA    AND 
SARCOMA. 

Carcinoma.  Sarcoma. 

Occurs  late  in  life.  Occurs  at  any  age,  most  commonly 

early  in  life. 

Not  encapsulated.  May  be  encapsulated  and  circum- 

scribed. 

Grows  less  rapidly.  Grows  more  rapidly. 

Adjacent  lymphatics  involved.  Lymphatics,  as  a  rule,  not  involved. 

Forms  metastases  through  the  Forms  metastases  through  the 
lymphatics.  blood-vessels. 

More  ajjt  to  form  metastases.  Less  apt  to  form  metastases. 

Tendency  to  ulceration.  Does  not  tend  to  ulcerate. 


Positive  diagnosis  can  generally  be  made  by  removing 
a  portion  of  the  growth  and  examining  under  the  micro- 
scope. 


I.  Epithelial  type. 


II.  Connective-tissue  type. 


1 66  SPECIAL   SURGERY 

NEW-GROWTHS  COMMONLY  ASSOCIATED  WITH  THE  FACE 
AND    JAWS. 

Papilloma  (warts). 
Adenoma  (salivary  glands) . 
Carcinoma  (epithelioma). 
Sebaceous  cysts. 

Fibroma  (in  subcutaneous  tissue). 
Lipoma  (in  subcutaneous  tissue). 
Angioma  (of  skin  or  gum). 
Chondroma. 
Osteoma. 
Osteosarcoma. 
Sarcoma. 
^  Giant-cell  myeloma. 

HI.  Mixed  type /  ^^'^^^  ^^^^^'^  °^  P"''^^^^  S^^^^" 

I  Odontoma. 

Carcinoma  may  affect  the  lip,  tongue,  cheek,  or  sali- 
vary glands,  particularly  the  parotid.  It  usually  takes 
the  form  of  epithelioma,  and  occurs  in  greatly  varying 
degrees  of  malignancy  (Fig.  41).  In  some  cases  it 
is  found  as  a  deep-seated,  slowly  spreading  ulceration  of 
the  cheek  (rodent  ulcer),  having  apparently  no  general 
ill  effects,  while  in  others  it  may  rapidly  infiltrate  the 
floor  of  the  mouth,  the  tongue,  cervical  lymphatics, 
pharynx,  and  larynx,  resulting  shortly  in  death. 

The  treatment  for  carcinoma  is  removal  if  seen  early 
enough.  The  entire  growth  and  some  healthy  tissue 
beyond  the  apparent  limits  of  the  disease  should  be 
removed.  This  includes  bone  and  cervical  lymphatics 
if  they  are  involved.  Secondary  operations  sometimes 
have  to  be  performed  to  make  flaps  to  cover  denuded 
areas,  and  prosthetic  appliances  may  be  used  to  replace 
lost  tissue. 


TUMORS 


167 


Fig.  41. — Rodent  cancer  of  the  face  (Fowler). 


Fig.  42. — Osteosarcoma  of  the  lower  jaw  (after  Cryei;. 

An  osteoma  i.s  a  simple  benign  tumor  of  l)one,  and  is 
rare  in  this  region  of  the  body.     Removal  of  the  growth 


1 68  SPECIAL   SURGERY 

will  not  be  followed  by  recurrence.  Bony  tumors  of 
the  jaws  are  usually  malignant,  osteosarcoma  (Fig.  42), 
and  are  to  be  treated  as  such — i.  e.,  by  removal  of  the 
whole  of  the  growth  and  some  of  the  surrounding 
healthy  tissue.  Sarcoma  frequently  affects  the  -upper 
jaw,  involving  the  maxillary  sinus. 


Fig.  43.— Epulis  (after  Cryer). 

Epulis  is  a  clinical  term  applied  to  the  commonest 
group  of  tumors  in  the  mouth.  From  the  derivation  of 
the  word,  it  is  any  growth  on  the  gum,  but  the  name  is 
usually  applied  to  a  circumscribed  connective- tissue 
growth  from  the  alveolar  ridge,  attached  with  a  broad 
or  narrow  pedicle,  and  covered  over  by  normal  mucous 


TUMORS 


169 


membrane,  except  as  the  latter  may  undergo  secondary 
ulceration  due  to  pressure  necrosis,  infection,  etc.  From 
both  the  cHnical  and  pathologic  standpoints  several 
varieties  are  described.  Fibrous  epuHs  is  hard,  grows 
slowly,  gradually  displacing  teeth  in  its  neighborhood, 
and  microscopically  is  a  fibroma.     A  second  variety  is 


Fig.  44. — Malignant  epulis  (Binnie). 


the  angiofibroma,  in  which  the  microscope  shows  numer- 
ous distorted  capillary  channels  running  through  the 
fibrous  tissue.  This  form  of  epuUs  presents  a  bright  red, 
spongy  appearance  and  bleeds  easily.  The  third  com- 
mon variety  of  epulis  is  the  giant-cell  myeloma,  which 
consists  of  a  stroma  of  fibrocellular  tissue,  with  numerous 
giant-cells   scattered   throughout.     These   growths   arc 


170  SPECIAL   SURGERY 

dusky  red  in  color  and  grow  with  comparative  rapidity. 
All  forms  of  epulis  spring  from  the  periosteum  or  from  the 
bone  itself,  and,  therefore,  to  prevent  recurrence  it  is  im- 
portant in  the  treatment  not  only  to  remove  the  apparent 
growth  itself,  but  also  to  curet  the  point  of  origin  or  bur 
away  some  of  the  bone  from  which  it  arises.  Teeth  in- 
volved in  the  growth  should  be  extracted.  If  left  they 
may  invite  recurrence  by  interfering  with  complete  re- 
moval of  the  tumor. 

The  use  of  the  actual  cautery  is  an  efficient  means  of 
controlHng  the  hemorrhage  when  operating  on  such  vas- 
cular structures. 

An  odontoma  or  odontome  is  a  tumor  derived  from  the 
special  cells  concerned  in  tooth  development  (James). 
In  general,  odontomas  may  be  classified  into  two  great 
groups,  the  solid  and  the  cystic.  The  commonest  form 
of  the  solid  group  is  the  calcified  composite  odontoma, 
which  consists  of  a  conglomerate  mass  of  tooth  struc- 
ture formed  of  the  various  component  tissues  of  a  tooth 
massed  together  without  any  definite  arrangement.  It 
usually  takes  the  place  of  one  of  the  natural  teeth,  and  in 
a  case  of  this  kind  one  of  the  normal  teeth  is  missing 
from  the  arch.  There  is  usually  a  swelling  of  the  jaw  in 
the  region  involved  which  may  cause  no  discomfort  un- 
less infection  takes  place.  If  the  latter  occurs,  the  swell- 
ing becomes  painful,  and  there  may  be  a  discharge  of 
pus  either  within  the  mouth  or  externally  through  sinuses 
leading  down  to  the  diseased  tooth  tissue.  The  x-ray  is 
useful  in  distinguishing  a  growth  of  this  kind  from  necro- 
sis of  the  jaw  bone.  The  treatment  consists  in  removal 
of  the  abnormal  tooth  structure. 


TUMORS  171 

The  principal  forms  of  cystic  odontomas  are  (i)  fol- 
licular and  (2)  radicular. 

(i)  The  follicular  cyst  or  odontocele  is  a  sac  lined  with 
epithelium,  filled  with  fluid,  and  containing  an  unerupted 
normal  or  abnormal  tooth.  It  is  caused  by  an  abnormal- 
ity in  development  of  the  dental  follicle.  The  accumula- 
tion of  fluid  causes  a  distention  of  the  jaw  bone,  the  bone 
oftentimes  becoming  so  thin  as  to  give  a  crackhng,  parch- 
ment-like sensation.  The  fluid  is  usually  clear  and  straw 
colored,  but  may  be  converted  into  pus  by  infection. 
The  treatment  consists  in  removal  of  the  encysted  tooth, 
evacuation  of  the  fluid,  and  removal  of  the  epithelial 
lining  of  the  cavity.  This  epithelium  secretes  the  fluid, 
and  if  not  throughly  removed  the  operation  may  be 
foflowed  by  recurrence. 

(2)  The  dental  root  cyst  is  a  growth  arising  about  the 
apex  of  an  erupted  tooth  that  has  usually  been  devital- 
ized, and  is  probably  the  result  of  infection,  whereby  the 
epithelial  cells  normally  found  in  the  peridental  mem- 
brane are  stimulated  to  grow  and  secrete  fluid.  The 
fluid  causes  a  destruction  and  sometimes  distention  of  the 
jaw  bone,  as  in  the  case  of  the  follicular  cyst.  Here,  too, 
the  fluid  is  normally  clear,  but  may  be  converted  into  pus 
by  secondary  infection.  The  treatment  consists  usually 
in  removal  of  the  affected  tooth,  evacuation  of  the  cyst 
contents,  and  removal  of  the  lining  membrane  by  curet- 
ment. 

Mixed  tumors  of  the  parotid  arc  composed  of  various 
tissues,  sometimes  even  containing  cartilage  and  bone. 


1/2  SPECIAL    SURGERY 


Leukoplakia 


Leukoplakia  consists  of  white,  slightly  raised  patches, 
varying  in  size  and  irregular  in  shape,  situated  on  the 
mucous  membrane  of  the  tongue,  cheek,  lips,  and  palate. 
They  are  especially  apt  to  be  found  on  the  part  of  the 
cheek  corresponding  to  the  line  of  occlusion  of  the  molar 
and  premolar  teeth.  The  patches  consist  of  dead  epi- 
thelium that  has  not  been  cast  off  from  the  mucous 
membrane. 

Etiology. — The  cause  is  not  known,  but  leukoplakia  is 
frequently  found  in  persons  with  unclean  mouths,  those 
who  use  tobacco  and  alcohol  to  excess,  or  who  are  fond 
of  hot  condiments,  pepper,  pickles,  etc.  In  some  cases 
the  disease  apparently  has  a  syphihtic  origin. 

Symptoms. — In  addition  to  the  description  already 
given,  the  patches  may  be  painful,  particularly  when 
anything  irritating  is  taken  into  the  mouth.  They 
cannot  be  scraped  off  without  leaving  an  ulcerated, 
bleeding  surface. 

Prognosis. — If  all  irritation  be  discontinued  after 
treatment  of  early  cases,  the  condition  is  not  likely 
to  return.  If  allowed  to  continue  without  treatment, 
leukoplakia  has  a  tendency  to  develop  into  epithelioma. 

Treatment. — This  consists  in  removal  of  the  patches, 
either  with  the  knife  or,  preferably,  with  the  actual 
cautery.  The  parts  are  then  to  be  kept  clean.  Chemic 
caustics  are  not  to  be  used,  as  they  only  cause  irritation 
and  tend  to  aggravate  the  condition. 


TUMORS  173 

Review  Questions 

Define  hNpertrophy,  hyperplasia,  neoplasm. 

Give  the  etiology,  symptoms,  and  treatment  of  the  various  forms  of 
hypertrophy  of  the  gums. 

Discuss  the  etiology  of  tumors.     " 

Give  a  classification  of  tumors. 

Give  the  clinical  classification  of  tumors,  and  two  examples  of  each 
variety. 

Give  the  varieties  of  carcinoma. 

Give  the  varieties  of  sarcoma. 

Give  the  differential  diagnosis  between  carcinoma  and  sarcoma. 

Name  several  of  the  commoner  tumors  of  the  face  and  jaws,  giving  the 
tissue  from  which  they  spring. 

Give  the  symptoms  and  treatment  of  carcinoma  of  the  lower  jaw. 

Give  the  pathology,  symptoms,  and  treatment  of  epulis. 

What  is  an  odontoma?     Give  treatment. 

Give  the  etiology,  symptoms,  prognosis,  and  treatment  of  leukoplakia, 


CHAPTER   XVII 
SYPHILIS  OR  LUES 

The  recognition  of  this  disease  by  the  dentist  is  very 
important,  as  he  is  at  any  time  liable  to  meet  with  its 
oral  manifestations,  some  of  which  are  among  the  most 
contagious  lesions  of  the  disease. 

Etiology. — Infection  occurs  through  some  break  in 
the  surface  of  the  skin  or  mucous  membrane.  It  may 
be  of  genital  or  of  extragenital  origin.  The  common- 
est mode  of  infection  is  through  sexual  intercourse, 
but  the  disease  may  be  acquired  innocently  through 
infected  drinking-cups  or  other  utensils,  a  razor,  kissing, 
etc.  Surgeons  have  become  infected  by  wounding  their 
fingers  while  operating  on  syphilitic  patients.  Infec- 
tion may  be  transmitted  from  one  patient  to  another  by 
unclean  surgical  or  dental  instruments.  The  infecting 
organism  is  the  spirochceta  pallida  or,  more  correctly, 
the  treponema  paUidum,  discovered  by  Schaudinn  about 
1905.  The  organism  can  be  found  in  lesions  of  all 
stages  of  syphilis.  It  is  a  pale,  spiral  organism,  with 
from  ten  to  twenty  turns,  a  fiagellum  at  either  end, 
and  is  endowed  with  active  motility.  It  can  only  be 
stained  by  special  methods.  It  is  taught  that  the  ter- 
tiary stage  of  syphilis  is  not  contagious.  In  this  stage 
probably  the  spirochetse,  though  they  are  present,  have 
lost  their  virulence. 

Syphilis  is  divided  into  the  primary,  secondary,  and 
tertiary  stages, 

(i)  Primary  Stage. — The  typical  lesion  is  the  chancre, 
which  appears  at  the  point  of  infection  about  three 

174 


SYPHILIS    OR  LUES  1 75 

weeks  after  exposure.  It  begins  as  a  small,  slightly 
raised  papule,  which  slowly  grows  larger,  and  finally 
breaks  down,  discharging  purulent  material,  leaving  a 
crater-like  ulcer,  the  size  of  a  twenty-five-cent  piece, 
with  raised  edges  and  indurated  base.  The  chancre  is 
very  rarely  painful.  At  the  same  time  there  is  an 
enlargement  of  the  lymphatic  glands  of  the  region, 
which  do  not  coalesce  and  are  not  painful. 

(2)  Secondary  Stage. — The  symptoms  of  this  stage 
begin  to  appear  about  six  weeks  after  the  chancre. 
There  is  a  general  adenopathy  or  lymphatic  enlargement, 
particularly  of  the  postcervical  and  epitrochlear  glands, 
anemia,  slight  fever,  headache,  joint  pains,  shedding  of 
the  hair,  iritis,  and  deafness.  The  principal  secondary 
symptom  is  the  skin  eruption.  This  begins  as  the 
roseolar  or  macular  eruption,  which  progressively  be- 
comes papular,  pustular,  and  even  ulcerative.  Examples 
of  all  these  lesions  may  be  found  at  the  same  time. 
They  occur  symmetrically  on  the  two  sides  of  the  body, 
vary  from  a  pin-head  to  a  split-pea  in  size,  and  do  not 
itch.  The  tubercular  syphilid  is  a  large  pustule  of 
the  secondary  stage  occurring  in  severe  cases. 

Mucous  patches  are  papules  occurring  on  moist  skin 
surfaces  or  on  mucous  membranes.  They  are  found  on 
the  genitalia,  under  the  breasts  of  women,  and  on  the 
mucous  membrane  of  the  mouth.  In  the  mouth  they 
usually  appear  first  on  the  tonsils,  then  at  the  sides  of 
the  tongue,  and  the  inner  surface  of  the  cheek  and  lips. 
Mucous  patches  are  oval,  grayish-white,  slightly  raised, 
and  moist,  and  leave  a  raw,  bleeding  surface  when  scraped 
away.  The  lesions  in  the  mouth  are  accompanied  by 
sore  throat  and  hoarseness. 


176  SPECIAL   SURGERY 

After  the  secondary  stage,  if  the  case  has  been  treated 
properly,  we  may  have  no  further  symptoms.  Other- 
wise there  is  an  intermediate  period  of  eighteen  months 
to  three  years,  followed  by  the  tertiary  stage. 

(3)  Tertiary  Stage. — Tertiary  symptoms  manifest 
themselves  in  the  skin  as  deep-seated  ulcers  known  as 
rupia,  which  ara  less  numerous  than  the  secondary 
eruption  and  are  not  symmetric.  In  other  tissues  the 
typical  tertiary  lesion  is  known  as  the  gumma,  which  is 
a  deep-seated  localized  softening,  which  becomes  ne- 
crotic, and  may  Kquefy  and  find  its  way  to  the  surface 
of  the  body,  discharging  a  dirty  brown  fluid.  Gummata 
may  be  found  in  any  tissue  of  the  body,  muscle,  bone, 
liver,  and  other  abdominal  organs,  tongue,  palate,  and 
brain.  When  they  break  down,  they  cause  great  loss 
of  tissue,  which  is  not  repaired. 

Oral  Manifestations  of  the  Different  Stages  of  Syph- 
ilis, and  the  Diagnosis  from  Other  Lesions. — ^The 
initial  lesion  of  syphilis  in  rare  cases  may  occur  on  the 
lip,  tongue,  palate,  or  tonsil.  This  is  associated  with 
early  enlargement  of  the  submaxillary  lymphatic  glands. 
Chancre  of  the  lip  is  to  be  diagnosed  from  epithelioma 
by  the  following  points: 

Chancre.  Epithelioma. 

May  occur  at  any  age  after  puberty.  Occurs  in  middle  age,  as  a  rule. 

Is  not  painful.  May  be  very  painful. 

Early  enlargement  of  submaxillary  Late  enlargement  of  submaxillary 

glands.  glands. 

Some  induration  at  base.  Wide-spread  induration. 

Followed  by  secondary  eruption.  Not  followed  by  skin  eruption. 

Improves  on   antisyphilitic  treat-  Not  improved  by  medicinal  treat 

ment.  ment. 

Develops  rapidly.  Develops  slowly. 

Spirochete  present.  Microscope  reveals  cancer  tissue. 


SYPHILIS   OR   LUES 


177 


In  the  secondary  stage  we  find  mucous  patches,  and 
the  patient  complains  of  sore  throat.  The  postcervical 
lymphatic  glands  are  enlarged. 

jMucous  patches  are  to  be  differentiated  from  leuko- 
plakia and  from  simple  ulcers. 


Mucous  Patches. 

May  occur  at  any  age. 
History  of  chancre  and  other  le- 
sions of  s>'philis. 
Glandular  involvement. 
Easily  scraped  off. 
Painless. 

Spirochaeta  pallida  present. 
Responds  to  treatment  by  mercury. 


Leukoplakia. 

Usually  occur  in  middle  life. 
History  of  excessive  smoking  or 
other  irritation  in  the  mouth. 
No  glandular  involvement. 
Scraped  off  with  difficulty. 
Painful. 
No  spirocheta. 
Does  not  respond  to  mercury. 


Simple  ulcers  are  rounded  instead  of  oval,  with  reddish 
borders,  are  painful,  and  there  are  no  other  lesions  of 
syphilis  present. 

In  the  tertiary  stage  we  may  find  a  gumma  of  the  tongue, 
lip,  cheek,  soft  palate,  or  hard  palate,  or  its  sequel, 
necrosis  of  the  bones  of  the  roof  of  the  mouth,  and 
cleft  palate  (Fig.  45). 

A  gumma  of  the  tongue  is  differentiated  from  car- 
cinoma of  the  tongue  as  follows: 


CiUNLMA. 

Not  painful. 

Develops  more  ra[)idly. 

V^ery  little  induration. 

History  and  other  signs  of  s>q)hili^ 


Carcinoma. 

Painful. 

Develops  more  slowly. 
Great  induration. 
Microscope  reveals  nature  of  the 
growth. 


Syphilitic  ulcer  is  to  be  differentiated  from  tuber- 
culous ulcer. 


12 


178 


SPECIAL    SURGERY 


Syphilitic  Ulcer. 
Not  painful. 

Rough,  undermined  edges. 
Spirochetae  may  be  found. 
History  and  other  lesions  of  syph- 
ilis. 


Tuberculous  Ulcer. 
Painful. 

Pale,  with  smooth  edges. 
Tubercle  bacilli  found. 
Other  lesions  of  tuberculosis. 


The  oral  manifestations  of  hereditary  syphiHs  are: 
Hutchinson's  teeth,  which  are  typically  seen  in  the  per- 
manent   central   incisors,    though   the    lateral    incisors 


Fig.  45. — Nasal  deformity  due  to  syphilis.  In  this  case  the  cartilaginous 
and  bony  septum  was  completely  destroyed,  allowing  the  nose  to  fall  in  and  the 
two  nostrils  to  become  fused  into  one  opening.  There  is  scarcely  any  trace  of  the 
alae  nasi  (Eisendrath). 

and  other  teeth  may  be  poorly  developed.  The  teeth 
are  barrel  shaped,  with  a  semilunar  notch  on  the  cutting- 
edge.     Cracks  or  fissures  (rhagades)  around  the  mouth 


SYPHILIS   OR  LUES  1 79 

are  common  in  infants  with  hereditary  syphilis,  which 
later  in  life  leave  radiating  linear  scars.  The  ordinary 
secondary  and  tertiary  symptoms — mucous  patches, 
glandular  enlargement,  gumma,  necrosis,  cleft-palate, 
etc. — are  found  just  as  in  acquired  syphilis. 

Newer  Methods  of  Diagnosis  and  Treatment. — Within 
the  last  ten  years  our  ideas  as  to  the  diagnosis  and  treat- 
ment of  syphilis  have  been  revolutionized  by  three  great 
advances:  (i)  The  estabhshment  of  the  Treponema  palli- 
dum as  the  cause  of  syphilis;  (2)  the  apphcation  of  the 
serum  complement-fixation  test  or  Wassermann  reaction; 
(3)  chemotherapy  by  means  of  organic  arsenical  com- 
pounds (salvarsan,  etc.). 

(i)  By  'means  of  the  dark  field  illuminator  micro- 
scopic diagnosis  may  be  made  early  in  a  large  proportion 
of  cases  by  finding  the  treponema  in  the  exudate  from  the 
primary  lesion,  where  formerly  it  was  frequently  neces- 
sary to  wait  until  secondary  symptoms  appeared  before 
a  diagnosis  of  syphilis  could  be  made.  We  are  now  in 
a  position,  therefore,  to  commence  treatment  several 
weeks  earlier  in  the  disease  than  formerly,  and  conse- 
quently with  a  greater  chance  of  cure. 

(2)  The  Wassermann  reaction  consists  in  the  detection 
in  the  blood  of  a  syphilitic  individual  of  certain  sub- 
stances produced  through  the  action  of  the  Treponema 
pallidum.  It  is  out  of  the  question  to  attempt  a  descrip- 
tion of  the  test  here,  and  the  reader  is  referred  to  works  on 
immunology  and  laboratory  diagnosis.  Of  far  greater 
importance  to  the  chnician  is  the  method  of  obtaining 
the  specimen  of  blood  from  the  patient  and  the  signifi- 
cance of  the  reaction. 

At  least  2  c.c.  of  blood  should  be  obtained  from  the 


l80  SPECIAL   SURGERY 

patient  either  by  puncturing  the  end  of  the  finger  or  by 
withdrawing  it  from  a  vein  at  the  bend  of  the  elbow  with 
a  hypodermic  syringe.  The  blood  should  be  placed  in  a 
sterile  tube  and  sent  to  the  laboratory  as  soon  as  possible 
for  examination.  The  patient  whose  blood  is  to  be  tested 
should  not  have  had  any  antisyphilitic  treatment  for  at 
least  three  weeks  prior  to  the  removal  of  the  blood. 
Otherwise  a  negative  reaction  may  be  obtained  in  a  case 
that  should  be  positive.  Alcohol  taken  within  the  pre- 
vious twenty-four  hours  may  have  the  same  effect. 
A  positive  Wassermann  reaction  means  the  presence  of 
living  spirochetes  in  the  body.  As  a  rule  the  test  does 
not  become  positive  until  at  least  two  weeks  after  the 
appearance  of  the  chancre,  so  for  positive  diagnosis 
earHer  than  this  we  resort  to  microscopic  examination  for 
the  Spirochaeta  pallida  in  the  exudate.  The  Wassermann 
reaction  is  strongly  positive  in  practically  every  case  of 
secondary  syphilis,  while  in  tertiary  syphilis  it  is  positive 
in  from  80  to  90  per  cent,  of  cases.  It  may  also  be  posi- 
tive in  cases  of  latent  syphihs  presenting  no  active  symp- 
toms. A  single  negative  Wassermann  reaction  does  not 
rule  out  syphihs.  A  strongly  positive  reaction  practically 
always  means  syphihs. 

(3)  For  the  past  five  years  a  synthetic  arsenical  com- 
pound discovered  by  Ehrlich,  dioxydiamidoarsenobenzol, 
known  under  the  trade  name  salvarsan,  and  popularly  as 
"606,"  has  been  extensively  used  in  the  treatment  of 
S5^hilis,  and  has  resulted  in  immense  improvement  over 
our  old  methods. 

Treatment. — The  treatment  of  syphilis  should  not 
be  commenced  until  the  diagnosis  of  the  primary  lesion 
is  certain.     This  may  be  made  in  the  great  majority  of 


SYPHILIS   OR   LUES  l8l 


cases,  especially  if  no  local  treatment  has  been  applied, 
by  microscopic  examination  of  the  exudate  from  the 
chancre  for  the  Treponema  pallidum  (Spirochaeta  pallida). 
Later  a  positive  Wassermann  reaction  will  be  obtained. 
In  cases  seen  early,  therefore,  it  is  seldom  necessary  to 
wait  until  secondary  symptoms  appear  before  beginning 
treatment.  It  is  now  recognized  that  vigorous  early 
treatment  with  modern  remedies  will  frequently  result 
in  a  rapid  cure,  even  in  the  prevention  of  secondaries  or 
of  a  positive  Wassermann  reaction. 

Before  commencing  antis^phiUtic  treatment  the 
mouth  and  teeth  should  be  got  into  the  best  possible 
condition.  Tartar  should  be  removed,  cavities  filled, 
and  all  useless  and  unhealthy  teeth  and  roots  extracted. 
The  patient  should  diligently  use  the  tooth-brush  and  a 
mouth-wash  during  the  entire  period  of  treatment. 
Danger  of  saHvation  by  mercury  is  thus  lessened. 
Mucous  patches  may  be  painted  with  a  solution  of 
chromic  acid,  4  grains  to  the  ounce  of  water. 

The  most  efhcient  treatment  for  syphilis  consists  in  the 
intravenous  administration  of  salvarsan,  the  average  dose 
being  0.6  gram.  One  injection  frequently  suffices  to 
make  all  symptoms  disappear  in  a  very  short  time,  though 
not  permanently.  But  in  the  majority  of  cases  two  or 
three  injections  at  intervals  of  a  week  or  ten  days  are 
necessary.  The  salvarsan  should  be  followed  by  mer- 
cury, for  example,  i  to  3  grains  of  the  protiodid  per  day 
by  mouth  for  several  weeks.  The  course  of  treatment 
should  be  guided  by  the  Wassermann  reaction.  A  reac- 
tion still  positive  after  a  full  course  of  treatment,  even  in 
the  absence  of  symptoms,  calls  for  more  salvarsan  and 
mercury.     After  cessation  of  treatment  the  serum  should 


1 82  SPECIAL   SURGERY 

be  tested  every  three  months  or  oftener  for  at  least  two 
years,  and  should  be  returned  negative  for  this  period 
before  the  patient  may  with  safety  be  pronounced  cured. 
As  a  rule,  the  later  in  the  course  of  syphilis  that  treatment 
is  begun  the  more  difficult  it  will  be  to  effect  a  cure,  as 
evidenced  by  disappearance  of  symptoms  and  perma- 
nently negative  Wassermann  reaction.  If  seen  in  the 
early  stages  we  are  justified  in  regarding  syphilis  as  a 
curable  disease. 

Mercury  may  also  be  given  in  the  form  of  mercurial 
ointment  as  inunctions  in  the  skin,  dose,  i  dram  daily, 
or  hypodermically  in  the  form  of  the  bichlorid,  2*4  grain 
daily.  In  late  cases  of  syphilis  mixed  treatment 
should  be  given,  i.  e.,  potassium  iodid  is  added  to  the 
mercury.  It  is  given  in  beginning  doses  of  10  grains, 
increased  up  to  i  dram  three  times  a  day.  The  potassium 
iodid  is  best  given  in  milk  after  meals. 

Review  Questions 

Give  the  etiology  of  sjT)hilis. 

Give  the  period  of  incubation  and  the  various  stages  of  syphilis,  with 
the  duration  of  each. 

Give  the  principal  lesions  of  the  three  stages  of  syphilis. 

Describe  the  oral  manifestations  of  the  three  stages  of  syphilis, 
acquired  and  hereditary. 

Give  the  differential  diagnosis  of  chancre  and  epithelioma  of  the  lip. 

Give  the  differential  diagnosis  of  mucous  patches  and  leukoplakia. 

Give  the  differential  diagnosis  of  gumma  of  the  tongue  and  carcinoma. 

What  do  you  know  of  the  serum  diagnosis  of  syphilis? 

What  is  the  prophylactic  mouth  treatment  in  syphilis?  Give  the 
principal  reason  for  carrying  it  out. 

Give  the  constitutional  treatment  of  syphilis. 

Discuss  the  "  salvarsan  "  treatment  of  syphilis. 


CHAPTER  XVIII 

STOMATITIS 
Stomatitis  is  inflammation  of  the  mucous  membrane 
of  the  mouth.     There  are  many  varieties  of  stomatitis— 
almost  as  many  as  the  causes  that  produce  it: 

1.  Simple  stomatitis. 

2.  Aphthous  stomatitis. 

3.  Ulcerative  stomatitis. 

4.  Gangrenous  stomatitis. 

5.  Parasitic  stomatitis  (thrush). 

6.  Toxic  stomatitis  (mercurial,  arsenical,  etc.). 

1.  Simple  or  catarrhal  stomatitis  is  usually  seen  in 
children,  and  is  caused  by  digestive  disturbances,  par- 
ticularly in  warm  weather,  and  bad  hygienic  surround- 
ings. 

The  symptoms  are  heat  and  tenderness  in  the  mouth, 
redness  of  the  mucous  membrane,  fetor  of  the  breath,  and 
fever. 

Treatment.-— Reguhte  the  bowels,  and  keep  the  mouth 
clean  with  a  solution  of  boric  acid. 

2.  Aphthous  stomatitis  presents  the  symptoms  of 
catarrhal  stomatitis,  with  the  addition  of  numerous 
small,  round,  yellowish-white  vesicles  on  the  lips,  cheek, 
and  tongue.  These  soon  break,  and  leave  small  shallow 
ulcers  with  a  red  areola. 

The  cause  of  aphthous  stomatitis  has  not  been  defin- 
itely settled.     Aphthae  are  liable  to  appear  in  the  mouths 

183 


184  SPECIAL   SURGERY 

of  children  during  the  digestive  disturbance  at  the  time 
of  teething.  The  general  opinion  now  tends  to  the 
belief  that  the  lesions  are  not  bacterial  in  origin,  but  have 
something  to  do  with  nervous  derangement. 

The  treatment  is  the  same  as  for  catarrhal  stomatitis. 

3.  Ulcerative  stomatitis  occurs  both  in  children  and 
in  adults,  and  is  usually  the  result  of  bad  hygienic 
surroundings.     It  sometimes  occurs  in  epidemics. 

Symptoms. — The  mucous  membrane  of  the  mouth  is 
very  much  inflamed,  breaks  down,  and  leaves  shallow 
ulcers  covered  with  yellowish  exudation.  The  breath  is 
extremely  fetid,  and  there  is  excessive  flow  of  saliva. 
The  infection  may  spread  to  the  sockets  of  the  teeth, 
causing  the  latter  to  loosen  and  drop  out.  Fever  and 
digestive  disturbances  are  often  associated  conditions. 

Treatment  — The  internal  administration  of  potassium 
chlorate  in  5-grain  doses  is  beneficial,  combined  with  a 
mouth-wash  of  potassium  chlorate  in  the  proportion  of 
10  grains  to  the  ounce  of  water.  The  teeth  should  be 
cleaned,  all  cavities  filled,  and  decayed  roots  removed. 
The  ulcers  may  be  touched  with  silver  nitrate,  pure 
carbolic  acid,  or  trichloracetic  acid.  The  application  of 
powdered  subnitrate  of  bismuth  to  the  ulcers  is  often 
soothing. 

4.  Gangrenous  stomatitis  is  a  further  stage  of  ulcera- 
tive stomatitis  in  which  the  destruction  of  tissue  extends 
beneath  the  mucous  membrane. 

Causes. — It  is  seen  in  persons  whose  vitality  has  been 
much  lowered,  as  through  alcoholism,  and  who  live  in 
poor  hygienic  surroundings.  These  factors,  in  conjunc- 
tion with  lack  of  attention  to  cleanliness  of  the  mouth 
and  teeth,  are  responsible  for  the  disease. 


STOMATITIS  185 

Symptoms. — The  disease  starts  as  an  ulcer,  usually 
in  the  vestibule  of  the  mouth,  which  becomes  larger, 
the  inflammation  spreading  to  the  deeper  tissues,  which 
slough,  forming  a  foul,  yellow,  stringy  mass.  The 
teeth  become  very  loose  and  may  be  lost.  The  flow  of 
saliva  is  increased,  and  the  swelling  interferes  with 
speech  and  mastication.  Marked  constitutional  symp- 
toms sometimes  are  present,  the  result  of  absorption  of 
toxic  matter  from  the  mouth.  The  temperature  may  be 
as  high  as  103°  F.,  and  the  pulse  weak  and  rapid.  The 
gangrenous  process  may  spread  through  the  cheek, 
or  the  infection  may  pass  into  the  deep  cellular  tissue  of 
the  neck  and  about  the  glottis,  suffocating  the  patient. 

The  prognosis  is  unfavorable,  probably  about  50  per 
cent,  of  the  cases  being  fatal. 

Treatment. — Local  measures  consist  in  keeping. the 
mouth  as  clean  as  possible.  The  stringy  necrotic  tis- 
sue should  be  trimmed  away  with  scissors  once  a  day, 
and  after  swabbing  the  surface  with  cotton  soaked  in 
dioxid  of  hydrogen,  it  should  be  touched  with  pure 
nitric  acid,  care  being  taken  not  to  allow  the  acid  to 
touch  other  than  the  parts  desired.  The  patient  should 
be  given  a  mouth-wash  of  potassium  permanganate 
I  :  2000,  which  should  be  used  frequently  throughout 
the  day. 

General  Treatment. — Where  constitutional  symptoms 
are  marked,  the  patient  should  have  rest  in  bed.  Stim- 
ulants and  tonics  are  indicated.  The  bowels  should  be 
freely  opened  with  calomel  in  repeated  doses  of  \  grain 
every  hour  for  four  doses,  followed  by  half  an  ounce  of 
magnesium  sulphate,  if  necessary.  Ten  or  fifteen  drops 
of  tincture  of  the  chlorid  of  iron  and  sV  grain  of  strychnin 


1 86 


SPECIAL   SURGERY 


four  times  a  day  are  usually  sufficient  in  the  way  of 
stimulation.  Half  an  ounce  of  whisky  four  times  a  day 
is  often  beneficial,  particularly  in  alcoholic  subjects. 

The  diet  should  be  liquid  at  first,  until  the  patient 
can  chew  and  swallow  solid  food.  As  soon  as  possible 
the  patient  should  be  allowed  to  sit  up,  as  the  danger  of 
pneumonia  is  thereby  lessened. 

Noma,  or  cancrum  oris  (Fig.  46),  is  a  form  of  gangren- 
ous stomatitis  occurring  in  infants,  sometimes  in  epi- 


Fig.  46. — Noma  (after  Schamberg). 

demic  form.  It  occasionally  follows  infectious  diseases, 
such  as  measles  or  whooping-cough,  and  occurs  in  badly 
nourished  children  in  poor  hygienic  surroundings. 

Various  forms  of  bacteria  have  been  isolated  from 
cases  of  the  disease,  and  the  spirillum  and  fusiform 
bacillus  described  by  Vincent  have  been  found. 

Symptoms. — The  disease  commences  as  a  swelling  of 
the  cheek,  with  fetor  of  the  breath  and  salivation.  This 
is  followed  by  a  small  ulcer  at  the  buccal  margin  of  the 


STOMATITIS  187 

gum,  which  rapidly  spreads  to  the  cheek  and  alveolar 
process.  The  tissue  of  the  cheek  becomes  black,  and 
finally  sloughs  away,  exposing  the  mouth.  The  disease 
is,  as  a  rule,  unilateral.  The  efTects  on  the  general 
system  are  very  marked.  The  temperature  is  high, 
the  pulse  weak  and  rapid,  and  the  child  lies  in  a  semi- 
comatose condition. 

Prognosis. — Nearly  all  cases  are  fatal. 

Treatment. — The  ulcer  should  be  cauterized  with 
nitric  acid  on  an  orange-wood  stick,  or  with  the  actual 
cautery.  The  parts  should  be  frequently  washed  with 
a  I  :  4000  solution  of  potassium  permanganate.  The 
gangrenous  tissue  of  the  cheek  must  be  removed.  If 
the  patient  survives,  the  resulting  disfigurement  may  be 
corrected,  to  some  extent,  by  plastic  operations.  The 
general  condition  of  the  patient  requires  stimulation  in  the 
form  of  strychnin  and  brandy.  The  latter  may  be  given 
in  doses  of  five  to  ten  drops  every  three  or  four  hours. 

5.  Parasitic  Stomatitis. — The  commonest  form  of 
stomatitis  parasitica  is  known  as  thrush,  and  is  due  to  a 
fungus — the  saccharomyces  albicans.  The  disease  oc- 
curs in  children  and  is  usually  associated  with  gastro- 
enteritis. 

The  mouth  presents  numerous  small  white  elevations 
which,  on  removal,  leave  a  raw  surface,  with  slight 
bleeding.  The  disease  affects  the  tongue,  cheeks,  lips, 
and  hard  and  soft  palate. 

Treatment  consists  in  removal  of  the  patches  by 
wiping  out  the  mouth  with  cotton  soaked  in  a  solution 
of  boric  acid  do  grains  to  the  ounce)  every  two  hours. 
Attention  should  also  be  given  to  the  general  condition 
of  the  j)atient. 


1 88  SPECIAL   SURGERY 

Vincent's  angina  is  an  exudative  inflammation  of  the 
pharynx  and  the  tonsils  which  occasionally  affects  the 
mouth.  It  is  characterized  by  the  formation  of  a  false 
membrane  resembling  that  of  diphtheria.  The  disease 
is  associated  with  the  presence  of  a  spirillum  and  a 
fusiform  bacillus,  described  by  Vincent,  which  are  readily 
stained  in  smears. 

In  the  mouth  the  grayish-white  patches  may  appear 
on  the  gums  about  the  necks  of  the  decayed  teeth. 
They  are  easily  removed,  leaving  an  eroded  surface. 
Sometimes  deeper  ulceration  occurs. 

The  treatment  is  the  same  as  for  thrush  and  for  ulcera- 
tive ■  stomatitis.  The  local  application  of  salvarsan 
powder  is  said  to  be  specific. 

Syphilitic  stomatitis  is  described  under  that  disease. 

6.  Toxic  Stomatitis. — Mercurial  stomatitis  is  an  in- 
flammation of  the  mouth  due  to  the  continued  adminis- 
tration of  small  doses  or  the  ingestion  of  large  doses  of 
mercury.    It  is  also  seen  in  artisans  who  work  in  mercury. 

The  inflammation  is  not  produced  by  the  direct  action 
of  the  mercury  itself  upon  the  oral  mucous  membrane, 
but  the  drug  lowers  general  vital  resistance,  thus  per- 
mitting the  growth  of  pathogenic  bacteria  within  the 
mouth.  Patients  taking  mercury  whose  mouths  have 
been  previously  put  in  hygienic  condition  and  are  kept 
clean  very  rarely  get  mercurial  stomatitis. 

Symptoms. — The  disease  starts  with  tenderness  of  the 
gums  and  pain  on  bringing  the  upper  and  lower  teeth 
together.  The  gums  around  the  necks  of  the  teeth  are 
reddened.  There  is  a  metallic  taste  in  the  mouth  and 
an  increase  in  saliva  (ptyahsm).  Later,  the  sahvation 
becomes  profuse,  there  is  intense  fetor  of  the  breath, 
and  the  gums  become  much  swollen  and  of  a  purple 


STOMATITIS  189 

color.  The  teeth  loosen  and  may  be  lost.  In  severe 
cases  ulceration  of  the  gums  and  necrosis  of  the  alveolar 
process  may  result. 

Treatment. — The  condition  can  practically  always  be 
prevented  by  appropriate  prophylactic  treatment  before 
putting  a  patient  on  a  course  of  mercury  and  by  careful 
watch  for  the  earliest  signs  of  the  onset  of  the  disease. 
Before  administering  mercury,  when  the  drug  is  to  be 
given  for  any  length  of  time,  the  mouth  should  be 
brought  into  a  thoroughly  hygienic  condition.  All 
deposits  should  be  removed  from  the  teeth,  cavities 
filled,  and  useless  roots  extracted.  During  the  entire 
course  of  treatment  by  the  mercur}-  a  mouth-wash  should 
be  used,  and  the  teeth  kept  thoroughly  clean.  If  the 
slightest  tenderness  of  the  teeth  on  bringing  them  to- 
gether occurs,  reduce  the  dose  of  mercury  to  one-half, 
and  if  the  s}Tnptoms  do  not  subside,  discontinue  the 
mercury  altogether  for  a  time.  The  mouth  must  be 
thoroughly  cleaned,  as  in  the  case  of  prophylactic  treat- 
ment. The  inflamed  gums  may  be  touched  once  daily 
with  tincture  of  iodin.  The  best  mouth-wash  is  a  i  :  2000 
solution  of  potassium  permanganate,  used  every  few 
hours.  A  I  :  6000  solution  of  bichlorid  of  mercury  some- 
times acts  well,  tending  to  show  that  it  is  not  the  local 
action  of  mercury  that  causes  the  stomatitis.  Potassium 
chlorate,  10  grains  to  the  ounce  of  water,  may  also  be 
used  as  a  mouth- wash.  Potassium  iodid  in  lo-grain 
doses  may  be  given  internally. 

Arsenic  may  cause  a  localized  inflammation  of  the 
gum  about  a  tooth  from  carelessness  in  its  use  in  devital- 
ization of  the  dental  pulp.  The  inflammation  may  spread 
to  the  deeper  tissues  and  cause  necrosis  of  the  bone. 


IQO  SPECIAL   SURGERY 

The  treatment  consists  in  the  immediate  appHcation 
of  the  antidote — dialyzed  iron — ^if  arsenic  is  accidentally 
allowed  to  touch  the  gum.  If  inflammation  occurs,  the 
gum  may  be  painted  with  tincture  of  iodin. 

Lead-poisoning  does  not  cause  stomatitis,  but  is 
often  manifested  in  the  mouth  by  a  blue  line  at  the 
margin  of  the  gums  around  the  necks  of  the  teeth. 
This  is  due  to  a  deposit  of  sulphid  of  lead  in  the  gum 
tissue,  and  not  on  the  teeth.  Consequently,  it  cannot 
be  scraped  off.  The  gums  are  not  inflamed.  Other 
symptoms  of  lead-poisoning  are  present,  including 
colic,  constipation,  wrist-drop,  etc. 

Review  Questions 

What  is  meant  by  stomatitis? 

Give  the  etiology,  symptoms,  and  treatment  of  ulcerative  stomatitis. 

Give  the  etiology,  symptoms,  and  treatment  of  gangrenous  stomatitis. 

What  is  noma?  Give  the  etiology,  symptoms,  prognosis,  and  treat- 
ment. 

What  is  Vincent's  angina? 

Give  the  etiology,  symptoms,  and  treatment  of  mercurial  stomatitis. 

What  are  the  oral  manifestations  of  lead-poisoning?  How  would 
you  diagnose  the  condition? 


CHAPTER  XIX 

ALVEOLAR   ABSCESS;    OSTEOMYELITIS;    NECROSIS  j 
ACTINOMYCOSIS 

Treatment  of  Alveolar  Abscess 
The  treatment  of  acute  alveolar  abscesses  differs  in  de- 
tails, but  not  in  principle,  according  as  to  whether  the 
offending  tooth  is  to  be  saved  or  not.  The  technic  of  treat- 
ment for  preservation  of  the  tooth  is  discussed  fully  in 
works  on  operative  dentistry.  While  it  is  possible  to  pre- 
serve and  render  useful  many  teeth  which  have  caused  al- 
veolar abscesses,  it  is  also  undoubtedly  true  that  too 
many  of  these  teeth  are  retained  and  remain  as  sources  of 
irritation  for  years.  There  is  also  a  general  hesitancy 
about  extracting  a  badly  decayed  tooth  that  is  causing  an 
alveolar  abscess.  The  patient  is  told  to  wait  until  the  ab- 
scess subsides,  as  extraction  might  cause  the  abscess  to 
spread.  The  patient  consults  the  family  physician,  who 
refers  him  back  to  the  dentist,  and  thus  the  abscess  often 
does  "spread,"  extending  to  the  bone,  setting  up  osteo- 
myehtis  and  necrosis. 

The  treatment  of  an  alveolar  abscess  caused  by  a  tooth 
too  badly  decayed  to  be  preserved  is  extraction  of  the 
tooth  as  soon  as  possible.  Frequently  this  will  be  all 
the  treatment  necessary,  as  the  pus  will  be  evacuated 
through  the  socket.  In  other  cases  the  pus  must  be 
allowed  to  escape  through  an  incision  made  in  the  gum 

191 


192  SPECIAL  SURGERY 

over  the  swelling.  Where  there  is  too  much  swelling 
to  render  an  attempt  to  extract  the  tooth  certainly 
successful,  this  should  be  first  reduced  by  letting  out 
the  pus,  but  the  tooth  should  be  removed  as  soon  as 
possible.  Dioxid  of  hydrogen  should  never  be  used  in 
these  cases,  either  in  cleaning  out  the  root-canal  when 
the  tooth  is  to  be  preserved,  or  in  the  abscess  cavity. 
An  attempt  should  always  be  made  to  prevent  the  pus 
from  an  alveolar  abscess  from  pointing  externally  on  the 
face  or  neck.  This  may  be  attained  by  early  incision 
within  the  mouth,  by  the  avoidance  of  hot  poultices 
or  hot-water  bags  on  the  face,  and  by  the  application 
of  cold  and  pressure  externally.  Chronic  abscesses  in 
which  there  is  necrosis  of  the  end  of  the  root  of  the  tooth 
are  sometimes  cured  by  so-called  amputation  of  the 
root,  but  frequently  do  not  heal  until  the  tooth  is  ex- 
tracted. It  is  unwise  to  attempt  to  save  teeth  that  have 
been  the  cause  of  abscesses  opening  into  the  maxillary 
sinus  or  externally  on  the  face  or  neck.  They  should  be 
extracted. 


Osteomyelitis  and  Necrosis  of  the  Jaw  bones 

Osteomyelitis  is  an  inflammation  of  the  marrow  of 
bone. 

Etiology. — General  diseases,  such  as  syphilis,  tubercu- 
losis, and  infectious  fevers,  interfere  with  the  nourish- 
ment of  bone,  giving  opportunity  for  the  entrance  and 
growth  of  pyogenic  micro-organisms. 

Local  infections  following  alveolar  abscess,  stomatitis, 
or  fracture  of  the  jaw  bone  may  set  up  osteomyelitis. 
The  use  of  dioxid  of  hydrogen  about  an  infected  area 


OSTEOMYELITIS  AND  NECROSIS  1 93 

communicating  with  the  bone  is  one  of  the  commonest 
causes  of  osteomyelitis.  When  this  drug  comes  in  con- 
tact with  organic  material  free  oxygen  is  given  off,  and  in 
an  inclosed  space,  such  as  an  alveolar  abscess  with  a 
small  opening,  it  produces  a  species  of  explosion,  driv- 
ing the  infected  material  before  it  through  the  cancel- 
lated tissue  of  the  bone.  The  hypodermic  injection  of 
cocain  or  any  drug  into  inflamed  tissues  to  produce  anes- 
thesia for  the  extraction  of  a  tooth  may  act  in  a  similar 
manner  by  carrying  infection  from  around  the  tooth  or 
from  the  gum  surface  into  the  surrounding  tissues  and 
thence  to  the  bone.  Osteomyelitis  may  thus  occur  quite 
independently  of  the  toxic  action  of  the  drug  itself. 

Poisons,  such  as  mercury,  arsenic,  cocain,  and  phos- 
phorus, cause  osteomyehtis  either  by  their  direct  action 
or  by  so  lowering  the  resistance  of  the  tissues  that  pyo- 
genic bacteria  gain  entrance. 

Mercury  may  cause  osteomyelitis  in  those  who  work 
with  the  metal,  or  the  disease  may  be  a  late  stage  of  the 
stomatitis  that  follows  overdosage  of  the  drug. 

Arsenic  and  cocain  may  cause  a  direct  poisoning  of 
the  tissues  when  applied  locally  as  therapeutic  agents. 

Phosphorus  causes  osteomyelitis  of  the  jaws  in  workers 
at  match-making  who  pay  little  or  no  attention  to  hygiene 
of  the  mouth.  The  phosphorus  in  solid  form  or  by  its 
fumes  probably  gains  entrance  to  the  jaw  bone  through 
devitalized  carious  teeth,  or  through  an  inflamed  peri- 
dental membrane.  The  white  or  yellow  phosphorus  is 
the  poisonous  form.  The  red,  amorphous  variety  is 
non-poisonous.  Since  the  passage  of  prohibitive  legis- 
lation against  the  use  of  white  phosphorus  in   match 

13 


194  SPECIAL   SURGERY 

manufacture  necrosis  from  this  source  has  been  elim- 
inated. 

Osteomyelitis  from  any  of  the  foregoing  causes 
usually  ends  in  necrosis  or  death  of  a  portion  of  the 
bone  en  masse.  Necrosis  may  also  be  caused  by  trau- 
matism, whereby  a  portion  of  the  bone  is  cut  off  from  its 
blood-supply.  Bones  are  nourished  through  blood- 
vessels derived  from  the  marrow  and  from  the  perios- 
teum, so  that  necrosis  is  essentially  the  result  of  star- 
vation from  interference  with  either  of  these  sources 
by  inflammation  or  injury,  or  by  derangement  of  the 
trophic  nerves,  which  govern  the  nutrition  of  the  bone. 

When  necrosis  occurs,  the  dead  bone  becomes  sepa- 
rated in  the  form  of  a  sequestrum.  The  periosteum,  if 
not  destroyed,  forms  a  shell  of  new  bone  about  the 
sequestrum,  known  as  the  involucrum.  Between  the 
two  the  inflammatory  process  goes  on,  forming  pus, 
which  makes  its  escape  through  openings  on  the  surface 
of  the  bone. 

Symptoms. — In  osteomyelitis  the  usual  signs  of 
inflammation  are  present.  There  are  deep-seated  pain 
and  tenderness  over  the  bone  affected.  In  the  case 
of  the  mandible,  the  side  of  the  face  affected  becomes 
greatly  swollen.  The  general  symptoms — fever  and 
prostration — are  usually  greater  than  those  caused  by 
an  ordinary  alveolar  abscess.  Grave  septicemia  and 
even  pyemia,  with  metastatic  abscesses  of  other  parts 
of  the  body,  may  result.  The  pus  eventually  makes 
its  way  to  the  surface  of  the  bone,  and  is  evacuated  in 
the  mouth  or  points  on  the  neck,  leaving  sinuses.  When 
necrosis  occurs,  the  sequestrum  can  be  felt  by  passing 
a  probe  up  the  sinus.     In  the  mouth,  the  appearance 


OSTEOMYELITIS  AND  NECROSIS  I95 

of  a  red  papilla  through  which  pus  exudes  is  an  indica- 
tion of  dead  bone  underneath.  In  the  early  stages  of 
necrosis  the  sequestrum  is  not  separated  from  the  rest 
of  the  bone,  but  later  it  becomes  quite  loose  and  maybe 
thrown  off  spontaneously. 

The  different  causes  of  necrosis  may  give  rise  to 
variations  in  the  character  of  the  sequestrum.  In 
syphilis,  the  dead  bone  is  usually  black  and  soft.  In 
tuberculosis  it  is  commonly  white  and  soft.  In  phos- 
phorus poisoning  it  is  white,  hard,  and  brittle,  giving 
rise  to  the  term  "pumice-stone  "  necrosis. 

The  necrosis  may  be  slight  in  extent,  or  it  may  involve 
the  entire  bone.  In  the  mandible,  providing  the  perios- 
teum is  not  destroyed,  an  entire  shell  of  new  bone  may 
be  formed.  Regeneration  of  bone  after  necrosis  in 
the  upper  jaw  is  rare.  The  x-ray  is  a  valuable  guide 
in  ascertaining  the  condition  of  the  bone  and  the  extent 
of  the  sequestrum. 

Treatment. — If  a  cause  be  present,  such  as  a  devital- 
ized tooth,  it  should  be  removed.  An  ice-cap  applied 
to  the  side  of  the  face  will  often  give  relief.  When 
there  are  indications  that  pus  is  present,  it  should  be 
evacuated,  through  the  mouth  if  possible,  and  if  not, 
by  as  small  an  external  opening  as  is  necessary  to  give 
drainage. 

When  dead  bone  is  felt,  the  surgeon  must  be  guided 
by  the  indications  of  the  individual  case  and  by  experi- 
ence whether  to  remove  it  or  wait  until  separation  of 
the  sequestrum  occurs.  It  is  better  to  remove  small 
portions  from  time  to  time  than  to  do  a  radical  operation 
too  early.  In  this  way  the  osteogenic  cells  are  more  likely 
to  be  preserved  for  the  formation  of  new  bone,  and  less 


196  SPECIAL   SURGERY 

disfigurement  results.  If  new  bone  is  formed  coinci- 
dentally  with  destruction  of  the  old  bone,  the  continuity 
of  the  jaw  is  preserved,  and  pathologic  separation  or 
fracture  through  the  diseased  area  is  not  so  liable  to 
occur.  Some  cases,  however,  on  account  of.  the  effects 
on  the  general  system,  demand  early  and  thorough 
eradication  of  the  necrotic  area.  A  cardinal  rule  is  to 
remove  sequestra  from  within  the  mouth  when  possible, 
thereby  avoiding  scars  on  the  face  and  neck. 

Loose  sequestra  should,  of  course,  be  removed  at 
once.  After  scraping  away  dead  bone  the  walls  of  the 
cavity  left  may  be  smoothed  by  the  surgical  engine. 
When  a  loose  sequestrum  has  been  taken  out,  the  walls 
of  the  cavity  will  have  a  smooth  and  velvety  feeUng  to 
the  finger.  After  the  operation  the  parts  may  be  lightly 
packed  with  a  strip  of  gauze  to  control  any  oozing; 
this  should  be  removed  on  the  following  day,  and  the 
mouth  syringed  out  with  a  solution  of  boric  acid  several 
times  a  day.  Dioxid  of  hydrogen  should  never  be  used 
to  irrigate  these  cases.  Sinuses  on  the  neck  will  close 
almost  immediately  if  all  the  dead  bone  has  been  removed. 
They  should  not  be  packed  with  gauze.  If  some  dead 
bone  remains,  suppuration  will  still  go  on  through  the 
sinus,  in  which  case  a  small  gauze  or  rubber  drain  may  be 
inserted  and  covered  with  a  sterile  gauze  pad  held  in  place 
by  a  modified  Barton  bandage. 

The  general  condition  of  the  patient  in  osteomyelitis 
and  necrosis  of  the  jaws  requires  careful  attention. 
If  there  is  much  fever,  the  patient  should  be  kept  in  bed, 
on  liquid  diet,  and  stimulation  given  if  required. 


actinomycosis  or  streptotrichosis      1 97 

Actinomycosis  or  Streptotrichosis 
This  is  a  chronic  infective  disease  occurring  in  cattle, 
and  rarely  in  man.  It  is  usually  due  to  the  actinomyces 
or  ray  fungus,  but  the  same  symptoms  may  be  caused 
by  other  allied  organisms  belonging  to  the  general 
streptothrix  group,  so  that  the  term  streptotrichosis 
is  preferable. 

The  appearance  of  the  lesion  varies  according  to  the 
part  affected,  and  the  presence  or  absence  of  pyogenic 
organisms.  The  head  and  neck  are  involved  in  more  than 
half  of  the  cases.  Frequent  involvement  of  the  jaw  gives 
rise  to  the  name  "  lumpy  jaw." 

Etiology.— The  ray-fungus,  or  streptothrix  bovis, 
is  the  usual  cause  of  the  disease.  It  appears  under 
the  microscope  as  a  mass  of  radiating  threads  with 
clubbed  ends.  Other  forms  are  found,  consisting  of 
branching  threads,  and  sometimes  with  spores.  The 
organism  is  believed  to  gain  entrance  into  the  body  by 
grain  or  straw,  causing  a  lesion  of  the  mucous  membrane 
of  the  digestive  or  respiratory  tract  or  the  skin.  The 
tonsils  or  carious  teeth  may  be  points  of  entrance. 
Thus  the  disease  is  particularly  apt  to  occur  in  persons 
residing  in  the  country. 

The  disease  spreads  in  the  body  by  a  gradual  invasion 
of  the  tissues  surrounding  the  point  of  inoculation.  It 
spreads  both  by  continuity  and  contiguity  of  tissue— that 
is,  it  passes  onward  without  regard  to  anatomic  boun- 
daries. The  lymphatics  are  not  apt  to  be  involved 
except  when  the  disease  is  associated  with  an  infection 
by  pyogenic  organisms.  Metastases  may  take  place 
through  the  veins. 

Symptoms.  In  cases  of  superficial  infection  the  dis- 
ease begins  as  a  small,  soft,  and  tender  nodule  which 


198  SPECIAL   SURGERY 

slowly  spreads,  giving  to  the  skin  a  purplish  mottling. 
The  nodules  break  down,  forming  sinuses  which  discharge 
a  thick  pus  in  which  the  typical  "  sulphur  granules  " 
are  found.  These  granules  are  composed  of  masses  of 
the  fungi,  which  can  be  demonstrated  under  the  micro- 
scope. It  is  practically  impossible  to  make  the  diagnosis 
without  the  microscopic  demonstration  of  the  organism. 

The  lesions  show  a  tendency  to  heal  in  one  portion 
and  to  break  down  in  another.  In  healing,  much  cica- 
tricial tissue  is  formed.  The  lesions  are  tender,  but  are 
not,  as  a  rule,  accompanied  by  great  pain.  The  chronic 
cases  rarely  present  constitutional  symptoms.  In  acute 
cases  complicated  by  infection  with  pyogenic  organisms, 
or  by  the  formation  of  metastases,  symptoms  of  septi- 
cemia or  of  pyemia  may  be  present. 

The  prognosis  of  chronic  and  localized  cases  depends 
on  the  situation  of  the  disease.  Where  vital  organs 
are  not  involved,  the  chances  for  recovery  are  good. 
The  principal  danger  of  the  disease  lies  in  the  intro- 
duction of  pyogenic  organisms  into  the  lesions,  result- 
ing in  septicemia  or  pyemia  The  formation  of  metas- 
tases also  renders  the  prognosis  unfavorable.  The 
mortality  of  superficial  lesions  is  about  10  per  cent., 
and  of  the  deeper  tissues  about  the  jaws,  30  per  cent. 

Treatment. — The  most  successful  forms  of  treatment 
are  the  internal  administration  of  potassium  iodid,  and 
total  excision  of  the  part  affected.  Potassium  iodid 
may  be  given  in  doses  of  15  to  60  grains  a  day.  Opera- 
tive interference,  in  which  all  the  diseased  tissue  could 
not  be  removed,  has  been  followed  by  rapid  metastases. 
Tincture  of  iodin  locally  may  have  a  beneficial  effect. 


ACTINOMYCOSIS   OR   STREPTOTRICHOSIS         I99 

Injection  of  killed  cultures  of  the  organism  has  met 
with  some  success. 

Review  Questions 

What  is  the  treatment  of  an  abscess  caused  by  a  decayed  tooth, 
opening  into  the  maxillary  sinus,  or  externally? 

Define  osteomyelitis.     Give  etiology. 

What  is  necrosis?     What  are  the  essential  factors  in  its  production? 

Define  sequestrum,  involucrum. 

Give  the  symptoms  of  osteomj^elitis  and  necrosis  of  the  mandible. 

Give  the  treatment  of  osteomyelitis  and  necrosis. 

Give  the  etiology,  symptoms,  prognosis,  and  treatment  of  actinomy- 
cosis. 


CHAPTER  XX 

DISEASES  OF  THE  MAXILLARY  SINUS 

The  maxillary  sinus  or  antrum  of  Highmore  may  be 
the  seat  of  catarrhal  inflammation,  empyema  or  sup- 
purative inflammation,  impacted  teeth,  tumors,  and 
polypi. 

Catarrhal  inflammation  is  usually  the  result  of  exten- 
sion of  catarrh  from  the  nose  and  associated  air-cells. 
The  inflammation  extends  from  the  middle  meatus  of 
the  nose,  by  way  of  the  hiatus  semilunaris  and  the 
ostium  maxillare.  The  mucous  membrane  becomes 
swollen  and  secretes  mucus.  The  swelling  of  the 
mucous  membrane  in  the  region  of  the  ostium  maxillare 
sometimes  shuts  off  that  opening,  and  the  accumula- 
tion of  mucus  gives  rise  to  pain  from  pressure.  In 
simple  acute  catarrhal  inflammation  of  the  antrum  it  is 
not,  as  a  rule,  necessary  to  open  into  the  sinus.  The 
inflammation  usually  subsides  by  spraying  and  applica- 
tions through  the  nose. 

Suppurative  inflammation  or  empyema  of  the  maxil- 
lary sinus  may  be  caused  by  infection  extending  from  the 
nose  and  associated  air-cells,  or  from  penetration  of 
bacteria  and  their  products  through  the  floor  of  the 
antrum  from  the  teeth.  The  latter  is  not  so  common 
as  might  be  supposed,  because  when  a  tooth  becomes 
diseased,  and  an  abscess  from  its  root  threatens  to 
break  into  the  antrum,  the  floor  of  that  cavity  over  the 

200 


DISEASES   OF  THE  MAXILLARY  SINUS  2OI 

particular  root  becomes  thickened  by  hyperplasia  of 
the  bone  tissue,  thus  protecting  the  antrum  from  in- 
fection. There  are  also  more  cases  in  which  teeth  are 
lost  through  diseases  of  the  antrum  than  cases  in  which 
the  teeth  are  primarily  diseased  and  cause  infection  of 
the  antrum.  Foreign  bodies,  such  as  rubber  drainage- 
tubes,  may  become  lodged  within  the  maxillary  sinus  and 
keep  up  chronic  suppuration. 

The  symptoms  of  acute  empyema  of  the  maxillary 
sinus  are  pain,  swelHng,  and  tenderness  over  the  affected 
side  of  the  face.  There  may  be  a  history  of  a  diseased 
tooth  on  the  affected  side  and  examination  may  reveal  it. 
Breathing  through  the  nose  on  that  side  may  be  impaired 
or  completely  obstructed.  A  flow  of  pus  from  the  nostril 
can  usually  be  obtained  by  holding  the  head  down  and 
forward  with  the  affected  side  uppermost.  Transil- 
lumination, by  placing  a  small  electric  light  in  the  mouth, 
may  show  a  dark  area  on  the  affected  side,  but  the  small 
size  of  the  antrum  may  make  this  sign  of  little  value. 
The  .T-ray  is  a  valuable  aid  in  diagnosis,  a  cloudiness  of 
one  side  of  the  face  often  indicating  maxillary  sinus 
disease.  The  x-ray  in  a  great  many  cases  shows  exactly 
which  tooth  is  involved. 

Chronic  suppuration  of  the  maxillary  sinus  may  be 
accompanied  by  little  or  no  pain  or  swelling,  and  the 
only  symptom  may  be  a  flow  of  pus  from  the  nostril 
or  an  opening  into  the  mouth.  A"  badly  decayed  tooth 
may  be  present,  the  a^-ray  showing  its  root  discharging 
into  the  sinus. 

Suppuration  of  the  maxillary  sinus  may  be  complicated 
by  infection  of  the  frontal  and  sphenoid  sinuses  and  the 
ethmoid  cells.   If  the  frontal  sinus  be  involved,  the  patient 


202  SPECIAL   SURGERY 

complains  of  pain  in  the  supra-orbital  region,  and  there 
will  often  be  a  flow  of  pus  from  above  into  the  anterior 
portion  of  the  nose.  When  the  sphenoid  and  ethmoid 
cells  are  affected,  the  pus  passes  backward  and  collects 
on  the  posterior  wall  of  the  pharynx. 

Treatment. — This  consists  in  making  an  opening  into 
the  maxillary  sinus  and  draining  it.  If  an  abscess  from 
a  diseased  tooth  has  opened  into  the  antrum,  the  tooth 
should  be  extracted  at  once.  Conservative  treatment 
of  the  tooth  should  not  be  attempted,  as  sufl&cient 
drainage  cannot  be  obtained  through  the  root.  After 
extraction  of  the  tooth,  usually  a  bicuspid  or  molar, 
the  opening  into  the  antrum  may  be  made  larger  by 
drilling  through  the  socket  with  the  surgical  engine. 

Selection  of  the  Place  of  Opening  the  Maxillary  Sinus 
when  No  Tooth-socket  is  Available. — There  are  three 
places  to  be  considered:  (a)  Through  the  canine  fossa. 
(b)  Through  the  nose,  (c)  Through  the  alveolar  process 
just  above  the  second  bicuspid  tooth. 

(a)  In  a  great  many  cases  an  opening  through  the 
canine  fossa  will  give  the  best  access  to  the  antrum, 
but  we  often  cannot  be  sure  that  an  opening  at  this 
point  will  not  enter  the  nose  instead  of  the  maxillary 
sinus.  The  opening  through  the  canine  fossa  also  may 
not  enter  the  lowest  point  of  the  sinus,  and  drainage 
will  be  imperfect. 

(b)  Drainage  through  the  nose  is  also  often  imperfect, 
and  in  making  an  opening  in  this  region  we  are  working 
in  the  dark,  to  a  large  extent. 

(c)  The  alveolar  process  over  the  second  bicuspid  tooth, 
or  the  same  region  if  the  tooth  has  been  previously  lost, 
is  for  most  cases  the  best  point  to  open  the  antrum, 


DISEASES   OF  THE   MAXILLARY  SINUS  203 

as  we  are  generally  sure  to  reach  the  antrum  from  this 
position,  and  drainage  is  more  perfect  as  the  cavity  is 
opened  at  its  lowest  point.  The  bone  also  is  usually 
thin  in  this  region.  Sometimes  a  counter-opening  from 
the  nose  is  advisable  for  freer  washing  out  of  the  cavity. 

After  the  antrum  has  been  opened,  it  is  washed  out 
several  times  with  warm  antiseptic  solution.  The  fluid 
should  be  forced  through  the  antrum  untils  it  runs  out 
from  the  nostril.  This  is  done  every  day  and  kept  up 
until  all  odor  and  discharge  disappear.  Drainage-tubes 
should  not  be  placed  in  the  opening.  If  this  threatens 
to  close  too  early,  a  small  plug  of  cotton  may  be  inserted 
daily.  If  the  discharge  is  slow  in  clearing  up,  tincture  of 
iodin,  a  few  drops  to  half  a  glass  of  water,  may  be  used 
in  flushing  out  the  cavity.  If  dead  bone  is  felt,  it  must 
be  removed,  and  necrotic  mucous  membrane  must  also 
be  scraped  away. 

Impacted  teeth  are  sometimes  lodged  in  the  wall  of  the 
maxillary  sinus.  Their  position  is  well  shown  by  the 
a*-ray.     Treatment  consists  in  removal. 

Tumors  of  various  kinds — carcinoma,  sarcoma,  osteo- 
sarcoma, etc. — may  involve  the  antrum.  Their  treat- 
ment is  by  early  operation,  just  as  in  the  case  of  malig- 
nant growths  of  other  regions. 

Polypi  are  pedunculated  growths  covered  by  mucous 
membrane.  They  are  an  overgrowth  of  the  submucous 
tissue  and  contain  cystic  areas  filled  with  mucus.  They 
usually  follow  chronic  inflammatory  conditions.  Another 
form  of  polyp  is  fibrous  in  character,  springing  from  the 
periosteum.  Polypi  are  felt  as  soft,  semisolid  masses 
that  bleed  easily. 

Treatment  is  by  enlarging  the  opening  into  the  antrum 


204  SPECIAL   SURGERY 

from  the  mouth  if  one  aheady  exists;  if  not,  make  a  new 
opening  with  the  surgical  engine,  grasping  the  polypi  with 
special  long-beaked  forceps,  and  twisting  or  tearing 
them  out.  Bleeding  after  removal  is  controlled  by 
packing  the  antrum  with  gauze,  which  is  changed  in 
twenty-four  hours,  for  three  or  four  days,  after  which 
the  opening  may  be  allowed  to  close. 

Review  Questions 

Name  the  principal  diseases  of  the  antrum  of  Highmore. 

Give  etiology,  symptoms,  and  treatment  of  empyema  of  the  antrum 
of  Highmore. 

What  factors  should  guide  the  operator  in  selecting  a  place  for 
opening  a  diseased  maxillary  sinus  when  no  tooth  socket  is  available? 

Give  the  diagnosis  and  treatment  of  polypi  of  the  maxillary  sinus. 


CHAPTER   XXI 

DISEASES    OF    THE    SALIVARY    GLANDS    AND    THEIR 

DUCTS 

The  salivary  glands  are  subject  to  inflammation  and 
tumors,  while  their  ducts  may  be  obstructed  by  in- 
flammation, tumors,  calculus,  or  foreign  bodies. 

Inflammation. — The  parotid  gland  is  subject  to 
epidemic  parotitis  or  mumps,  a  specific  inflammation, 
the  nature  of  which  is  not  known,  and  infection  by 
various  bacteria.  Typhoid  fever  is  sometimes  followed 
by  suppuration  of  the  parotid  gland. 

Tumors. — The  most  common  tumors  of  the  parotid 
gland  are  the  so-called  mixed  tumors,  or  teratomata, 
which  consist  of  several  varieties  of  tissue,  including 
fat,  fibrous  tissue,  muscle,  glandular  tissue,  and  car- 
tikge. 

Carcinoma  of  the  parotid  gland  sometimes  occurs, 
but  is  rare. 

A  swelling  over  the  region  that  may  be  mistaken  for 
a  tumor  of  the  parotid  gland  is  sometimes  caused  by 
enlargement  of  the  lymph-node  which  lies  over  the 
gland. 

Swelling  of  the  parotid  gland,  whether  due  to  inflam- 
mation or  neoplasm,  is  generally  associated  with  false 
ankylosis  of  the  temporomandibular  joint.  The  patient 
has  pain  and  difficulty  in  opening  the  mouth.  There  is 
also  nearly  always  some  facial  paralysis  on  the  affected 

205 


206  SPECIAL   SURGERY 

side,  due  to  pressure  on  the  filaments  of  the  seventh 
nerve  as  they  pass  through  the  parotid  gland. 

The  submaxillary  gland  may  also  be  affected  by  in- 
flammation of  tumors.  These  give  rise  to  a  swelling  in 
the  submaxillary  triangle. 

Stenson's  duct,  the  outlet  of  the  parotid  gland,  some- 
times becomes  obstructed  by  an  extension  of  inflamma- 


Fig.  47. — Ranula.  Note  the  prominent  tumor  on  right  side  of  floor  of  the  mouth, 
pushing  the  tongue  upward  (Eisendrath). 

tion  from  the  mucous  membrane  of  the  mouth.     It  may 
be  relieved  by  probing. 

Ranula. — Obstruction  of  the  ducts  of  the  submaxillary, 
sublingual,  or  mucous  glands  gives  rise  to  a  swelling  in 
the  floor  of  the  mouth  caused  by  retention  of  the  secretion 
of  these  glands,  known  as  ranula  (Fig.  47).  A  ranula 
is,  therefore,  a  retention  cyst. 


DISEASES   OF  SALIVARY  GLANDS  AND  DUCTS      20/ 

Etiology. — The  obstruction  may  be  caused  by  sali- 
vary calculus  or  a  foreign  body,  such  as  a  tooth-brush 
bristle,  within  one  of  the  ducts,  or  by  inflammation  or  a 
tumor  involving  or  causing  pressure  upon  the  ducts. 
The  encysted  material  may  be  mucus,  cheesy  matter, 
or  hard  calculus. 

Symptoms. — The  floor  of  the  mouth  presents  a  smooth 
sweUing,  usually  soft,  of  a  grayish  color,  which  pushes 
the  tongue  up  and  interferes  with  eating  and  speech. 
The  tongue  may  protrude  from  the  mouth.  There  is, 
as  a  rule,  very  little  pain  associated  with  the  swelling, 
which  slowly  increases  in  size.  Puncture  of  the  swelHng 
is  followed  by  a  flow  of  thick  mucus,  the  retained  secre- 
tion of  the  gland  involved.  When  the  swelling  contains 
calculus,  it  is  hard. 

Treatment. — This  consists  in  attempting  to  open  the 
duct  of  the  gland  by  dislodging  the  cause  of  the  obstruc- 
tion and  evacuating  the  fluid.  If  this  cannot  be  done, 
a  new  outlet  is  to  be  made.  This,  in  some  cases,  may  be 
brought  about  by  means  of  a  "  seton,"  which  is  a  piece 
of  silk  ligature  passed  through  the  mucous  membrane 
near  the  duct  with  a  curved  needle  and  tied  in  place. 
The  silk  sloughs  off  in  a  few  days,  leaving  a  new  opening. 
In  other  cases  a  V-shaped  flap  is  cut  in  the  mucous  mem- 
brane over  the  swelling,  turned  in,  and  sutured.  Some- 
times the  entire  sac  must  be  dissected  out. 

Salivary  fistula  is  a  communication  of  one  of  the 
salivary  glands,  usually  the  parotid,  with  the  surface  of 
the  face,  through  which  the  saliva  is  discharged.  Saliv- 
ary fistula  is  caused  by  obstruction  or  injury  to  Stenson's 
duct,  which  may  be  due  to  traumatism,  such  as  a  gun- 
shot-wound, carelessness  or  unavoidable  injury  in  opera- 


2o8  SPECIAL   SURGERY 

tions  in  the  region  of  the  duct,  obstruction  of  the  duct 
from  calculus  or  inflammation,  or  ulceration  following 
malignant  disease.  The  opening  on  the  face  is  just 
beneath  the  zygoma,  and  is  usually  very  resistant  to 
treatment,  owing  to  retraction  of  the  scar  tissue  and 
the  constant  escape  of  saliva. 

Treatment. — Any  obstruction  to  the  normal  outlet  of 
saliva  into  the  mouth  must  be  first  removed,  if  possible, 
or  a  new  connection  made  between  the  duct  and  the 
mouth.  After  this  has  been,  done,  the  opening  on  the 
face  must  be  closed  by  cutting  the  scar  tissue  away  from 
the  bone,  to  which  it  may  be  very  adherent,  freshening 
the  edges  of  the  opening,  and  bringing  them  together 
with  sutures.  Sometimes,  when  a  large  space  is  to  be 
filled,  it  is  necessary  to  close  the  opening  with  a  flap  of 
skin  turned  up  from  the  neck. 

Ludwig's  Angina. — Ludwig's  angina  is  the  name  given 
to  a  rapidly  spreading  celluhtis  of  the  tissue  beneath  the 
floor  of  the  mouth. 

Etiology  and  Pathology. — The  infection  gains  entrance 
through  the  roots  of  decayed  teeth,  through  peridental 
inflammation,  through  the  tonsils,  or  through  the  ducts 
of  the  submaxillary  glands.  The  invading  organism  in 
the  majority  of  cases  is  the  Streptococcus  pyogenes.  The 
inflammation  first  involves  the  submaxillary  lymphatics, 
and  spreads  thence  into  the  surrounding  cellular  tissue, 
passing  sometimes  into  the  region  of  the  glottis. 

Symptoms. — The  disease  begins  as  a  swelhng  in  the 
floor  of  the  mouth,  accompanied  by  pain  and  increased 
flow  of  sahva.  Later,  the  submaxillary  region  becomes 
indurated,  swollen,  and  tender.     The  rapid  increase  in 


DISEASES   OF  SALIVARY  GLANDS  AND  DUCTS      2O9 

the  swelling  and  in  the  other  symptoms  is  character- 
istic of  the  disease,  its  entire  course  sometimes  not  occu- 
pying more  than  twenty-four  or  forty-eight  hours.  The 
mucous  membrane  of  the  floor  of  the  mouth  may  be 
pushed  up  to  the  level  of  the  tops  of  the  lower  incisor 
teeth.  The  tongue  is  forced  up,  causing  the  mouth  to 
be  held  open.  The  disease  usually  commences  on  one 
side,  but  not  infrequently  both  sides  soon  become  in- 
volved. The  local  symptoms  are  often  accompanied 
by  high  temperature  and  rapid  pulse,  and  the  patient 
may  be  prostrated  by  absorption  of  the  toxic  products 
of  the  infection.  The  cellulitis  may  rapidly  spread  to 
the  glottis,  causing  suffocation  of  the  patient. 

Prognosis. — If  the  case  is  seen  very  soon  after  its 
onset  and  proper  treatment  instituted,  recovery  gener- 
ally follows.  Cases  seen  late,  or  allowed  to  go  without 
proper  treatment,  are  usually  rapidly  fatal. 

Treatment. — This  consists  in  free  external  incision 
and  drainage  as  soon  as  possible  after  the  diagnosis  has 
been  made.  Incision  in  the  floor  of  the  mouth  is  not 
sufficient.  Two  openings  should  preferably  be  made,  one 
in  the  median  line  of  the  neck,  just  beneath  the  chin, 
and  the  other  laterally,  in  the  submaxillary  triangle. 
The  incisions  must  be  carried  beneath  the  deep  fascia, 
for  this  is  where  the  inflammation  is  taking  place.  The 
two  openings  should  be  connected  by  passing  hemostatic 
forceps  from  one  to  the  other,  and  a  rubber  drainage-tube 
inserted  between  them.  Pus  usually  is  not  obtained 
in  early  cases,  but  this  incision  almost  invariably  checks 
the  spread  of  the  inflammation  The  incision  in  the 
median  line  may  be  carried  up  to,  but  should  not  pass 
through,  the  mucous  membrane  of  the  mouth.     At  this 

14 


210  SPECIAL   SURGERY 

point,  as  in  the  case  of  all  median  raphes,  no  blood-vessels 
are  apt  to  be  wounded.  These  incisions  are  usually 
followed  by  subsidence  of  the  swelHng  within  a  few  hours, 
accompanied  by  a  fall  of  temperature  and  general  im- 
provement in  the  patient's  condition.  The  opposite 
state  of  affairs  has  been  seen  so  often  to  follow  postpone- 
ment of  free  incision  that  delay  is  to  be  severely  con- 
demned. If  the  case  is  seen  late,  when  the  process  has 
begun  to  occlude  the  glottis,  tracheotomy  in  addition  to 
the  other  measures  offers  the  only  hope  of  recovery. 
The  general  condition  of  the  patient  requires  hquid  diet 
and  stimulants 

Review  Questions 

Give  several  causes  and  the  effects  of  swelling  of  the  parotid  gland. 
Give  the  etiology,  varieties,  symptoms,  and  treatment  of  ranula. 
Give  the  etiology  and  treatment  of  salivary  fistula. 
Define  and  give  the  etiology,  pathology,  symptoms,  prognosis,  and 
treatment  of  Ludwig's  angina. 


CHAPTER  XXII 

DISEASES  OF  THE   TONSILS  AND  OF  THE  LYMPHATIC 
GLANDS 

The  tonsils  normally  undergo  atrophy  as  age  advances, 
but  may  become  hyper tropied,  in  which  case  they  are 
subject  to  attacks  of  inflammation,  form  points  of 
entrance  for  pathogenic  bacteria  into  the  system,  and 
give  rise  to  various  pathologic  conditions. 

In  hypertrophy  of  the  tonsils  the  organs  are  enlarged, 
and  either  project  toward  the  median  line,  narrowing 
the  lumen  of  the  oropharynx,  or  are  buried  behind  the 
pillars  of  the  fauces.  While  the  former  give  rise  to 
excessive  mouth-breathing  and  its  sequels,  it  is  the  latter 
that  act  as  a  constant  menace  to  the  health  of  the  indi- 
vidual from  the  absorption  of  pathogenic  bacteria. 

It  is  doubtful  whether  hypertrophy  of  the  tonsils 
causes  a  narrowing  of  the  bony  palatal  arch.  It  cer- 
tainly narrows  the  lumen  of  the  oropharynx,  thus  in- 
creasing the  mouth-breathing,  which  is  normal  in  all 
cases,  to  a  certain  extent.  In  this  way  irregularity  of 
the  teeth  may  result,  because  the  normal  hammering 
action  of  the  mandible  is  absent  (Fig.  48). 

The  treatment  of  hypertrophy  of  the  tonsils  consists 
in  removal  of  the  organs.  This  is  best  done  by  enuclea- 
tion by  blunt  dissection,  followed  by  the  use  of  a  snare. 
It  is  impossible  to  completely  remove  the  buried  variety 
of  hypertrophied  tonsil  by  cutting  with  the  ordinary 
tonsillotome,  and  this  is  the  variety  that  demands 
removal  most  frequently.     In  operations  on  the  tonsil 

211 


212  SPECIAL   SURGERY 

care  must  be  taken  not  to  wound  the  internal  carotid 
artery,  which  Hes  externally  to  it,  being  separated  from 
the  tonsil  by  the  superior  constrictor  muscle  of  the  phar- 
ynx. The  ascending  pharyngeal  artery  is  more  likely  to 
be  wounded,  but  is  a  much  smaller  vessel,  and  is  not  apt 
to  give  rise  to  serious  hemorrhage  if  divided. 


Fig.  48. — Facial  expression  in  hypertrophied  tonsils  and  adenoids  (St.  Clair 

Thomson). 

Tonsillitis. — The  tonsils  are  subject  to  several  varieties 
of  inflammation,  which  will  only  be  mentioned  briefly. 
The  two  commonest  forms  are  follicular  tonsillitis  and 
suppurative  tonsillitis,  or  quinsy,  A  convenient  method 
of  removing  pus  from  the  region  of  the  tonsil  and  without 
danger  of  causing  undue  hemorrhage  is  by  thrusting  the 
end  of  a  grooved  director  into  the  abscess. 

The  tonsils  are  the  most  frequent  seats  of  diphtheric 
infection.     This  produces  a  grayish-white  membrane  of 


DISEASES  OF  TONSILS  AND  L  YMPHA  TIC  GLANDS  2  I  3 

necrotic  tissue  over  the  tonsil.  Smears  and  cultures 
made  from  this  membrane  contain  diphtheria  bacilli. 

The  secretion  of  the  tonsillar  crypts  often  collects 
behind  the  anterior  pillar  of  the  fauces,  giving  a  foul 
odor  to  the  breath.  Many  of  these  cases  come  with  the 
idea  that  the  odor  is  due  to  decay  of  the  teeth.  Examina- 
tion reveals  no  cavities  in  the  teeth,  but  small,  cheesy 
masses  of  the  tonsillar  secretion  are  found  behind  the 
anterior  pillar  of  the  fauces,  and  the  removal  of  this  by 
wiping  with  cotton  gives  immediate  relief. 

Adenoids. — Adenoid  growths  are  hypertrophy  of  the 
lymphoid  tissue  which  normally  lies  beneath  the  mucous 
membrane  of  the  nasopharynx.  These  growlhs  obstruct 
the  posterior  nares,  preventing  nasal  breathing,  thus 
giving  the  mouth  abnormal  respiratory  work  to  do,  and 
causing  in  this  way  the  same  conditions  as  hypertrophy 
of  the  tonsils.  Deafness  may  also  result  from  occlusion 
of  the  Eustachian  tube.  Adenoids  are  felt  by  passing 
the  finger  up  behind  the  soft  palate. 

The  treatment  consists  in  removal  of  the  growths  by 
a  special  curet. 

The  Lymphatic  Glands 

The  lymphatics  most  frequently  affected  by  lesions  of 
the  mouth  and  jaws  are  the  submaxillary  group.  When 
enlarged,  the.se  are  felt  immediately  beneath  the  lower 
border  of  the  mandible,  in  the  submaxillary  triangle  of 
the  neck.  These  glands  may  be  enlarged  from  inflam- 
mation or  malignant  disease  of  the  region. 

Inflammation. — The  most  common  inflammatory  con- 
ditions causing  enlargement  of  the  submaxillary  lymph- 
glands  are  inflammation  of  the  tonsils,  inflammation 


214  SPECIAL    SURGERY 

about  the  roots  of  teeth,  and  osteomyelitis  of  the  mandible. 
These  structures  must,  therefore,  be  examined  in  search- 
ing for  a  cause  of  the  swelling.  The  glands  are  also 
subject  to  tuberculous  infection.  Inflammation  of  the 
submaxillary  lymph-glands  (lymphadenitis)  may  be 
acute  or  chronic.  In  the  acute  form  there  is  a  painful 
tender  swelling  beneath  the  lower  border  of  the  jaw,  which 
may  go  on  to  suppuration.  The  treatment  consists  in 
removal  of  the  cause,  application  of  cold  or  soothing 
ointment,  such  as  ichthyol,  and  pressure.  If  pus 
forms,  the  neck  must  be  opened  and  drained. 

Chronic  lymphadenitis  is  characterized  by  nodular 
swellings  in  the  submaxillary  region,  which  may  or  may 
not  be  tender.  The  swellings  tend  to  remain  about  the 
same  size  for  a  long  period.  The  treatment  is  to  remove 
the  cause  if  it  can  be  found-,  and  if  this  is  not  followed  by 
subsidence  of  the  swelling,  the  glands  should  be  dis- 
sected out. 

Malignant  Disease. — Carcinoma  of  the  tongue,  floor 
of  the  mouth,  or  of  the  mandible  is  usually  accompanied 
sooner  or  later  by  enlargement  of  the  submaxillary 
lymphatic  glands.  This  enlargement  may  at  first  be 
due  to  absorption  of  infectious  material  from  ulceration 
of  the  tumor,  but  is  also  caused  by  a  growth  of  tumor- 
cells  in  the  glands.  Hence  the  glands,  if  involved, 
should  always  be  removed  at  the  time  of  operation  on 
the  primary  focus. 

Review  Questions 

What  pathologic  conditions  may  be  caused  by  hypertrophied  tonsils? 

What  are  adenoid  growths?  Give  the  symptoms,  diagnosis,  patho- 
logic effects,  and  treatment. 

What  conditions  may  cause  swelling  of  the  submaxillary  lymph- 
glands? 


CHAPTER  XXIII 

INJURIES    AND   DISEASES    OF    THE  TEMPOROMANDIB- 
ULAR ARTICULATION 

Dislocation 

By  dislocation  or  luxation  (Fig.  49)  is  meant  an 
alteration  in  the  relation  of  the  bony  surfaces  composing 

a  joint. 

One  or  both  temporomandibular  joints  may  be 
affected,  double  luxation  being  more  frequent.  The 
dislocation  may  be  complete  or  incomplete. 

Displacement.— The  condyle  of  the  mandible  is  always 
carried  forward.  It  is  prevented  from  passing  back- 
ward by  the  tympanic  plate  of  the  temporal  bone. 
Hence,  posterior  dislocation  is  unknown  unless  accom- 
panied by  fracture  of  this  plate  of  bone.  In  complete 
dislocation  the  condyle  of  the  mandible  passes  out  of 
the  glenoid  fossa,  under  the  eminentia  articularis  into 
the  zygomatic  fossa,  accompanied  by  the  interarticular 
fibrocartilage,  and  is  held  there  by  contraction  of  the 
temporal  and  masseter  muscles.  The  capsular  ligament 
of  the  joint  is  torn  and  other  ligaments  are  put  upon  the 
stretch. 

In  incomplete  dislocation  or  subluxation  the  condyle 
of  the  mandible  rests  on  the  eminentia  articularis. 

Etiology.— Dislocation  of  the  jaw  is  caused  by  any 
force  which  produces  an  overopening  of  the  mouth. 
A  blow  on  the  chin  while  the  mouth  is  open,  undue 

215 


2l6  SPECIAL   SURGERY 

forcing  open  the  mouth  in  the  extraction  of  a  tooth,  and 
yawning  are  among  the  numerous  causes  of  dislocation. 
Some  individuals  have  the  power  of  producing  a  dis- 
articulation at  will,  and  in  them  the  luxation  gives  rise 
to  little  or  no  discomfort. 


Fig.  49.— Dislocation  of  temporomandibular  joint. 

Symptoms. — In  double  luxation  the  mouth  is  held 
wide  open  and  cannot  be  closed,  interfering  with  mastica- 
tion and  speech.  The  chin  is  protruded  beyond  the 
normal.  There  are  hollow  spaces  in  front  of  the  ears, 
where  the  condyles  ought  to  be.  Considerable  pain 
is  complained  of. 

In  dislocation  of  one  joint  only,  the  chin  is  protruded 
and  deflected  toward  the  sound  side,  and  there  is  a 


THE    TEMPOROMANDIBULAR  ARTICULATION     2  1/ 

hollow  space  in  front  of  the  ear  on  the  affected  side. 
Single  luxation  is  not  so  common  as  double. 

Treatment. — When  seen  early,  a  case  of  dislocation  of 
the  temporomandibular  joint  may  be  difficult  to  reduce, 
owing  to  the  rigidity  of  the  temporal  and  masseter 
muscles,  but  in  an  hour  or  two,  when  the  muscles  have 
relaxed,  the  condyle  usually  slips  back  into  place  easily. 
It  may  be  necessary  to  anesthetize  the  patient.  Reduc- 
tion is  brought  about  by  covering  the  thumbs  with  a 
towel,  and  placing  them  one  on  each  side  of  the  mouth, 
to  the  outer  side  of  the  molar  teeth.  The  other  fingers 
are  placed  under  the  chin.  By  downward  pressure  of 
the  thumbs  and  lifting  the  chin  with  the  fingers,  the 
condyle  is  carried  under  the  eminentia  articularis  into 
the  glenoid  fossa.  After  reduction  of  the  dislocation 
the  Barton  bandage  should  be  applied  and  worn  for 
two  weeks.  After  this  time  massage  and  passive 
motion  may  be  begun. 

Old  dislocations  that  resist  all  attempts  at  reduction 
require  osteotomy  at  the  angle  of  the  mandible. 

Ankylosis 

By  the  term  ankylosis  is  meant  partial  or  total  im- 
mobility of  a  joint. 

The  following  varieties  of  ankylosis  of  the  temporo- 
mandibular joint  arc  found: 

{a)  True  Ankylosis. — Immobility  due  to  disease  within 
the  joint  itself.  This  is  usually  complete,  owing  to  a 
deposit  of  bone  in  and  around  the  joint.  Ossification 
may  be  preceded  by  fibrous  or  cartilaginous  change  in 
the  joint,  in  which  case  the  ankylosis  would  be  in- 
complete. 


2l8  SPECIAL    SURGERY 

Etiology. — True  ankylosis  of  the  temporomandibular 
joint  is  usually  found  in  osteoarthritis,  a  chronic  disease, 
in  which  all  the  joints  of  the  body  are  progressively 
affected  by  ossification  of  the  joint  structures.  Bony 
union  of  the  joint  surfaces  and  surrounding  parts  also 
occurs  after  traumatism.  After  prolonged  ankylosis 
characteristic  changes  take  place  in  the  shape  of  the 
mandible.  The  condyloid  process  is  shortened.  This 
causes  an  apparent  elongation  of  the  coronoid  process. 
The  angle  of  the  mandible  is  elongated,  so  that  it  forms 
a  projecting  point,  and  the  base  of  the  bone  under  the 
mental  foramen  is  thickened.  The  mental  process  is 
much  diminished  in  size  by  recession.  The  base  of  the 
bone,  between  the  angle  and  a  point  vertically  under  the 
canine  tooth,  is  deeply  concave  in  outline. 

The  cause  of  these  changes  lies  in  the  activity  of  the 
muscles  that  depress  the  jaw.  The  muscles  of  mastica- 
tion— I.  e.,  those  which  elevate  the  lower  jaw — are  in- 
active, while  those  which  assist  in  depressing  the  man- 
dible become  more  and  more  active  in  their  work  in  an 
endeavor  to  overcome  the  fixation  of  the  temporo- 
mandibular articulation.  By  their  action  the  lower  jaw, 
from  the  symphysis  to  the  angle,  becomes  modified  in 
proportion  to  the  contraction  of  the  depressing  muscles 
of  the  lower  jaw.  Anteriorly,  there  are  the  geniohyo- 
glossus,  the  sternohyoid,  the  sternothyroid,  the  digastric, 
the  omohyoid,  and  the  platysma  myoides,  all  of  which 
are  abnormally  active.  Their  action  without  the  com- 
pensating factor  of  the  mandibular  motion  brings  about 
the  changes  noted  ^  (Figs.  50  and  51). 

{h)  False  ankylosis  is  partial  immobility,  due  to  changes 
'  Cryer,  "  Studies  in  the  Internal  Anatomy  of  the  Face. " 


THE    TEMPOROMAXDIBULAR   ARTICULATIOy      219 

in  structures  outside  the  joint.    It  may  be — (i)  chronic, 
(2)  acute. 

Chronic  false  ankylosis  of  the  temporomandibular 
joint  may  be  due  to  (a)  trauma,  resulting  in  thickening 
of  the  ligaments,  or  formation  of  scar  tissue  from  a 
wound  in  the  region  of  the  joint. 


Fig.  so. — .\rikyi(^.^i.^  o(  jaw  (allcr  L  rycry 


(b)  Inflammatory  conditions,  followed  by  organiza- 
tion of  exudate  or  formation  of  scar  tissue  about  the 
joint. 

ic)  Cicatricial  tissue  following  sloughing  within  the 
mouth  in  the  course  of  acute  exanthemata  (scarlet  fever, 
etc.). 


220 


SPECIAL    SURGERY 


The  changes  in  the  shape  of  the  mandible  following 
prolonged  ankylosis  of  this  character  are  similar  to 
those  seen  in  acute  ankylosis. 


L- 

Fig.  51. — Radiograph  of  ankylosis  of  temporomandibular  joint,  showing  under- 
development of  mandible  and  impaction  of  teeth  (after  Cryer). 

Acute  false  ankylosis  is  inability  to  move  the  jaw,  owing 
to  an  acute  inflammatory  exudate  in  the  region  of  the 
joint.  This  is  often  seen  in  connection  with  mumps  and 
other  inflammations  of  the  parotid  gland.     An  impacted 


THE    TEMPOROMANDIBULAR  ARTICULATION     221 

third  molar  tooth  or  an  abscess  from  a  tooth  often 
causes  celluhtis,  which  extends  up  to  the  region  of  the 
joint. 

Symptoms. — Complete  True  Ankylosis. — Complete  im- 
mobility of  the  temporomandibular  joint  is  rare.  There 
is  absolute  inabihty  to  open  the  mouth.  After  a  time 
the  chin  recedes,  the  angle  of  the  jaw  becomes  obtuse, 
and  the  muscles  below  the  jaw  have  the  appearance  of 
being  tense.  If  ankylosis  dates  from  childhood,  the 
teeth  are  found  to  be  irregular  and  some  of  them  im- 
pacted, owing  to  lack  of  space  for  eruption.  The 
x-rays  are  of  great  value  in  these  cases  in  ascertaining 
the  condition  of  the  joint,  and  also  because  inability  to 
open  the  mouth  makes  examination  by  the  ordinary 
methods  difficult  or  impossible. 

True  ankylosis  that  has  not  become  complete  and  chronic 
false  ankylosis  present  symptoms  that  vary  only  in 
degree.  Here  the  jaws  can  be  separated  to  a  slight 
extent.  There  is  no  pain,  except  when  force  is  used  to 
open  the  mouth.  The  secondary  changes,  recession  of 
the  chin,  impaction  of  teeth,  etc.,  are  found  as  in  the 
case  of  bony  ankylosis. 

Acute  False  Ankylosis. — Here  we  have  the  symptoms 
of  acute  inflammation — heat,  pain,  redness,  swelHng, 
and  disturbed  function — in  the  region  of  the  joint.  The 
motion  of  the  lower  jaw  is  limited  owing  to  the  pain  and 
exudation,  and  the  patient  has  difficulty  in  opening  the 
mouth.  The  local  signs  may  be  accompanied  by  fever 
and  other  general  symptoms.  In  inflammations  of  the 
parotid  gland  the  swelling  is  triangular  in  shape,  behind 
the  ramus  of  the  jaw  and  in  front  of  the  ear.  The 
limitation  of  jaw  movement  in  these  cases  is  due  largely 


222  SPECIAL   SURGERY 

to  inflammation  of  the  process  of  parotid  gland  that  is 
found  in  the  glenoid  fossa,  though  it  is  also  brought  about 
by  the  general  swelling  behind  the  ramus.  This  form  of 
ankylosis  often  gives  rise  to  great  alarm  on  the  part  of 
the  patient  and  family,  who  fear  the  onset  of  tetanus. 

Prognosis  and  Treatment. — In  true  ankylosis  of  the 
temporomandibular  joint  the  prognosis  is  unfavorable. 
Where  bony  union  of  the  parts  has  taken  place,  it  is 
never  possible  to  restore  the  function  of  the  joint. 
In  this  case  the  only  hope  of  improvement  is  by  making 
a  false  joint  (pseudo-arthrosis) .  It  is  best  to  do  this 
by  removing  a  wedge-shaped  piece  of  bone  at  the  angle 
of  the  mandible,  rather  than  section  at  the  neck  of  the 
condyle.  This  may  be  done  by  making  a  section  at  the 
neck  of  the  condyle,  or  by  removing  a  wedge-shaped 
piece  of  bone  at  the  angle  of  the  mandible.  A  flap  of  soft 
tissue  is  interposed  between  the  cut  ends  of  bone,  and 
after  the  operation  motion  is  begun  early  to  prevent  the 
formation  of  new  bone  at  the  point  of  section. 

In  incomplete  ankylosis,  whether  true  or  false,  the 
prognosis  is  more  favorable,  and  great  improvement  can 
sometimes  be  brought  about.  Cicatricial  tissue  or  fibrous 
bands  which  restrict  the  movement  of  the  jaw  may  be 
cut  away  by  operation,  and  the  jaws  gradually  spread 
apart  by  a  special  appliance,  or  they  may  be  gradually 
stretched  without  operation.  A  special  wedge  is  made, 
the  jaws  of  which  are  spread  wider  apart  little  by  little 
each  day.  Wedge-shaped  pieces  of  box-wood  or  ivory 
may  also  be  introduced  between  the  upper  and  lower 
teeth,  and  the  patient  instructed  to  work  the  jaws  with 
the  wedge  in  position.  In  this  way  great  progress  may 
be  made,  the  final  result  obtained  depending  on  the 
severity  of  the  case. 


THE    TEMPOROMANDIBULAR  ARTICULATION     22  3 

In  acute  ankylosis  the  prognosis  is  good,  and  the  treat- 
ment consists  in  removal  of  the  cause.  If  it  be  an  im- 
pacted or  abscessed  tooth,  this  should  be  removed.  Anes- 
thesia is  often  necessary  to  get  the  mouth  open.  The 
inflammation  is  treated  by  rest,  cold,  soothing  lotions, 
incision,  etc. 

Differential  Diagnosis  of  Tetanus  and  Acute  Ankylosis. 
— The  muscles  of  the  jaw  are  those  earliest  affected  in 
tetanus  (lockjaw),  and  this  fact  often  leads  to  alarm  on 
the  part  of  the  patient  suffering  from  acute  ankylosis 
that  he  has  an  attack  of  lock-jaw.  There  is  no  necessity, 
however,  for  the  surgeon  to  confuse  the  two.  In  the 
trismus  of  tetanus  or  lock-jaw  the  inability  to  open  the 
mouth  is  purely  due  to  muscular  spasm,  and  is  not  in- 
flammatory, consequently  there  is  no  swelling  in  the  re- 
gion of  the  temporomandibular  joint.  The  muscular 
contractions  are  intermittent.  The  convulsions  are  not 
confined  to  the  muscles  of  the  jaw- ,  except  in  the  earliest 
stages,  but  are  general;  there  are  severe  constitutional 
symptoms,  and  the  patient  is  very  much  prostrated. 
Spasm  of  the  muscles  of  the  back  causes  a  marked  arch- 
ing (opisthotonos),  so  that  the  patient  may  be  supported 
by  his  head  and  heels.  In  tetanus  there  is  generally  a 
history  of  a  punctured  wound,  such  as  that  made  by 
a  rusty  nail  in  the  foot,  a  gun-shot  w^ound,  etc. 

Review  Questions 

Give  the  displacement,  etiology.  symi)toms,  and  treatment  of  luxation 
of  the  temporomandibular  joint. 

What  is  meant  by  ankylosis?  Give  the  varieties  of  anl^ylosis  of  the 
temporomandibular  articulation  and  the  causes  of  each. 

(iive  the  symjitoms  of  the  fh'ffcrent  varieties  of  anl<ylosis  of  the  tem- 
pf)romandibular  joint. 

Ciive  the  pro(?nosis  and  treatment  of  the  different  varieties  of  ankylosis. 

Give  the  diflerential  diagnosis  of  tetanus  and  acute  ankylosis  of  the 
temporomandibular  joint. 


CHAPTER  XXIV 
IMPACTED  TEETH 

The  term  impaction  has  been  used  to  describe  a 
tooth  that  is  prevented  from  erupting,  being  deflected 
from  its  normal  Hne  of  movement  so  that  it  impinges 
on  an  adjacent  tooth.  This  impingement  may  permit 
of  partial  eruption  or  entirely  prevent  it.  The  same 
term  is  also  apphed  to  other  malpositions,  rotations,  and 
inversions  of  unerupted  teeth. 

Order  of  Impaction. — The  tooth  most  frequently 
impacted  is  the  lower  third  molar.  This  is  closely 
followed  by  the  upper  canine  and  the  upper  third  molar. 
Other  teeth  are  occasionally  impacted,  but  not  so 
frequently  as  those  mentioned.  The  explanation  is 
easily  seen.  The  third  molar,  being  the  last  of  the 
posterior  teeth  to  erupt  normally,  the  space  reserved 
for  it  is  readily  filled  up  by  abnormal  conditions.  The 
canine,  in  relation  to  the  anterior  teeth,  suffers  similarly 
from  lack  of  space  when  this  part  of  the  jaw  is  affected. 

Impacted  teeth  are  found  in  various  positions,  shapes, 
and  degrees  of  impaction.  Sometimes  they  are  partially 
erupted  and  can  be  seen,  but  often  they  are  entirely 
covered  by  the  gum  and  the  bone.  An  impacted  lower 
third  molar  usually  lies  more  or  less  horizontally,  press- 
ing at  various  angles  against  the  second  molar.  This 
tooth  may  be  impacted  without  pressing  against  the 
second  molar,  and  may  be  rotated  in  various  directions, 

224 


IMPACTED    TEETH 


225 


pointing  back  toward  the  ramus,  or  it  may  be  completely- 
inverted  (Figs.  52  and  53). 

The  upper  third  molar  is  usually  impacted  with  its 
crown  pressing  against  the  second  molar.  Its  roots  may 
apparently  pass  into  the  maxillary  sinus,  as  shown  by 


^ 


^-^4-1  r-^ 


'-^ 


Fig.  52. — Side  view  of  two  impacted  lower  third  molars,  the  bone  having  been 
removed  in  order  to  expose  the  roots  (after  Cryer). 

the  a:-ray,  but  this  occurs  very  seldom,  the  roots  really 
being  in  the  wall  of  the  sinus,  above  the  level  of  the 
floor. 

An  impacted  canine  tooth  is  usually  prevented  from 
eruption  by  the  roots  of  adjacent  incisors  or  premolars, 
against  which  it  presses. 

15 


226 


SPECIAL    SURGERY 


The  roots  of  impacted  and  misplaced  teeth  are  often 
built  into  abnormal  shapes  during  their  development  in 
order  to  avoid  encroachment  upon  important  structures, 
such  as  the  maxillary  sinus,  the  inferior  dental  tube,  etc. 


Fig-  53- — Radiograph  showing  impacted  lower  third  molar  tooth,  with  resorption 
of  root  of  second  molar;  also  impacted  upper  third  molar  (after  Cryer). 

Etiology. — Many  pathologic  conditions  bring  about 
retarded  eruption,  displacement,  and  impaction  of  the 
teeth. 

General    Disturbances. — Acute    infectious    fevers    of 


IMPACTED    TEETH  22/ 

childhood,  such  as  scarlet  fever  and  measles,  and  disor- 
ders of  nutrition,  such  as  scurvy.  Local  causes  are  in- 
flammations of  the  jaw  bones  set  up  by  decayed  teeth  or 
other  causes,  injury,  contracted  arches  produced  by 
excessive  mouth-breathing  the  result  of  nasal  obstruction 
from  adenoids,  etc.  The  growth  of  the  jaws  and  the 
movement  of  the  teeth  are  in  a  forward  direction; 
consequently,  anything  which  interferes  with  this  for- 
ward movement  or  growth  will  cause  impaction  of  the 
teeth.  Acute  infectious  fevers  interfere  with  the  for- 
ward movement  by  causing  a  deposit  of  dense  bone. 
Local  increase  in  the  density  of  the  bone  may  also  be 
brought  about  by  inflammation  of  the  peridental  mem- 
brane extending  into  the  alveolar  process.  The  can- 
cellated tissue,  instead  of  being  spongy  and  elastic,  be- 
comes hard  and  soUd.  This  condition  following  caries 
of  the  first  permanent  molar  soon  after  its  eruption  is  a 
frequent  cause  of  impaction  of  the  lower  third  molar. 

The  effects  of  contracted  arches  of  constant  mouth- 
breathers  on  the  eruption  and  position  of  the  teeth  are 
well  known.  Severe  traumatism  to  the  jaws  may  cause 
a  deposit  of  lime  salts  in  the  cancellated  tissue  and  thus 
bring  about  impaction.  A  heavy  blow  on  the  chin  in 
childhood  may  produce  ankylosis  of  the  temporo- 
mandibular joint,  resulting  in  arrest  of  growth  of  the 
jaws,  leaving  insufficient  space  for  the  eruption  of  all 
the  teeth.  Too  early  extraction  of  deciduous  teeth  may 
cause  malposition  of  the  permanent  teeth,  this  leading  in 
turn  to  impaction  of  uneruptcd  teeth.  Failure  to  lance 
the  gums  in  retarded  eruption  of  deciduous  teeth  may 
bring  about  an  abnormal  density  of  the  cancellated 
tissue,  resulting  in  impaction  of  permanent  teeth.     In 


228  SPECIAL    SURGERY 

addition  to  injury,  disease,  and  lack  of  development,  it 
is  conceivable  that  impacted  teeth  may  result  from 
hereditary  causes,  such  as  transmission  of  small  jaws 
from  one  parent  and  small  teeth  from  the  other.  Irreg- 
ularities are  artificially  produced  in  certain  animals  by 
breeders,  and  the  same  thing  occurs  in  the  human  race 
accidentally. 

Symptoms  and  Diagnosis. — Impacted  teeth  may  be 
present  without  giving  rise  to  any  symptoms  whatever. 
Others  cause  pain,  which  may  be  local  or  neuralgic 
in  character,  distributed  along  the  branches  of  the 
trifacial  nerve.  Sometimes,  in  the  case  of  the  lower  third 
molar,  cellulitis  is  set  up,  which  produces  false  ankylosis 
of  the  temporomandibular  joint.  If  the  tooth  is  partly 
erupted,  the  diagnosis  is  at  once  apparent,  but  in  other 
cases  the  diagnosis  depends  on  the  absence  of  the  tooth 
from  the  denture  and  the  a;-ray  findings. 

Impacted  teeth  are  a  frequent  cause  of  many  serious 
local  and  general  disturbances. 

Local  Effects. — An  impacted  third  molar  may  press 
against  the  crown  of  the  second  molar  and  cause  decay 
of  that  tooth,  or  itself  become  the  seat  of  caries  around 
the  point  of  contact.  Exposure  and  devitalization  of 
the  pulp  from  this  cause  may  give  rise  to  neuralgia. 
Neuralgia  may  be  caused  in  another  way  by  pressure 
of  the  roots  of  the  impacted  tooth  on  the  inferior  den- 
tal nerve  and  its  branches.  The  irritation  set  up 
by  an  impacted  tooth  may  cause  condensation  of  the 
surrounding  bone,  with  pressure  on  the  nerve  and  its 
branches.  Infection  from  a  pulp  devitalized  by  pres- 
sure of  an  impacted  tooth  may  pass  up  into  the  maxil- 
lary sinus  and  other  pneumatic  spaces. 


IMPACTED    TEETH  229 

General  Effects. — Impacted  teeth  can  set  up  functional 
nervous  and  possibly  mental  disease,  even  though  they 
cause  no  local  symptoms. 

Treatment. — This,  as  a  general  rule,  consists  in  re- 
moval, by  operation,  of  the  impacted  tooth.  In  some  cases 
it  is  more  advisable,  on  account  of  the  difficulty  in  reach- 
ing the  misplaced  tooth,  to  extract  the  adjacent  tooth 
that  is  causing  the  obstruction.  After  this  has  been 
done  the  impacted  tooth  will  in  many  cases  erupt  in 
the  position  of  the  extracted  tooth.  This  procedure  is 
sometimes  advisable  even  in  cases  where  the  third  molar 
could  be  easily  reached,  especially  where  the  second 
molar  is  badly  decayed.  It  is  occasionally  necessary 
to  sacrifice  both  the  second  and  third  molars.  Some- 
times the  impacted  tooth,  a  lower  third  molar,  for  ex- 
ample, can  be  turned  out  of  its  socket  by  inserting  a 
No.  3  elevator  between  it  and  the  second  molar,  but 
generally  some  of  the  dense  bone  overlying  the  tooth 
must  first  be  cut  away  with  a  bur  in  the  surgical  engine. 
The  tooth  can  then  be  turned  out  with  the  elevator  or 
grasped  by  the  forceps.  In  many  cases  the  extremely 
dense  character  of  the  bone  makes  removal  of  a  consid- 
erable quantity  necessary  before  the  tooth  can  be  re- 
moved. 

Indications  for  Extraction  of  Deciduous  Teeth. — The 
deciduous  teeth  should  be  retained  if  possible  until  time 
for  the  eruption  of  the  permanent  teeth,  as  they  are  guides 
to  the  correct  eruption  of  the  latter.  On  the  other 
hand,  retention  of  deciduous  teeth  that  are  badly  decayed 
is  a  frequent  cause  of  inflammatory  conditions  result- 
ing in  increase  in  density  of  the  jaw  bones,  followed  by 
maleruption  and  impaction  of  the  permanent  teeth. 


230 


SPECIAL   SURGERY 


The  deciduous  teeth  should  be  extracted,  therefore: 
(i)  When  they  are  so  badly  decayed  as  to  give  rise 
to  continual  pain  which  cannot  be  relieved. 

(2)  When  they  interfere  with  the  correct  eruption  of 
the  permanent  teeth. 

(3)  When  they  remain  in  position  after  eruption  of 
the  corresponding  permanent  teeth. 

Review  Questions 

Define  the  term  impacted  tooth.     Give  etiology,  effects,  diagnosis, 
and  treatment  of  impacted  teeth. 

Give  the  indications  for  extraction  of  the  deciduous  teeth. 


CHAPTER   XXV. 
MALFORMATIONS  OF  THE   JAWS 

Cleft-palate 

By  cleft-palate  (Fig.  54)  is  meant  the  formation  of 
an  opening  in  the  hard  or  soft  palate  or  both,  affording 
a  communication  between  the  oral  and  nasal  cavities. 

Varieties. — Cleft-palate  may  be: 

1.  Acquired. 

2.  Congenital. 

I.  Acquired  cleft-palate  may  be  due  to — 

(a)  Traumatism,  as  a  gunshot  wound  or  blow. 

(b)  Disease,  such  as  syphilis,  which  causes  necrosis 
of  the  bones.  Acquired  clefts  vary  very  greatly  in  size. 
The  opening  may  be  merely  a  small  round  hole  or  cleft, 
it  may  involve  only  the  soft  palate,  or  it  may  be  so  large 
as  to  convert  the  mouth  and  nose  into  practically  one 
cavity  by  destruction  of  the  whole  of  the  hard  and  soft 
palates. 

Treatment. — Acquired  cleft-palate  is  treated  by  ob- 
turators and  artificial  vela,  after  the  parts  have  been 
brought  into  as  healthy  a  condition  as  possible  by  remov- 
ing necrotic  tissue,  internal  medication,  etc.  The 
simplest  form  of  obturator  is  nothing  more  than  a  plate 
of  metal  or  rubber,  covering  a  break  in  the  hard  palate. 
Obturators  which  correct  breaks  in  the  soft  palate,  being 
mobile  in  construction,  are  known  as  vela.     A  velum  is 

231 


232  SPECIAL   SURGERY 

used  not  only  to  fill  a  space,  but  also  to  assist  in  a  func- 
tional performance.  It  is  designed  to  take  the  place  of 
the  soft  palate  in  swallowing. 

The  best  method  of  taking  the  impression  of  a  cleft- 
palate  is  by  filling  the  cleft  with  absorbent  cotton 
smeared  with  vaselin.     This  prevents  the  plaster  from 


Fig.  54. — Double  cleft-palate  and  harelip.  View  of  interior  of  mouth:  P, 
Skin  in  median  line  covering  the  intermaxillary  bone,  the  projecting  portion 
of  the  latter  being  seen  immediately  below  it;  M,  intermaxillary  bone;  C,  C 
palatal  processes  of  the  right  and  left  superior  maxillae  respectively;  the  black 
space  between  C  and  M  on  each  side  of  the  median  line  represents  the  cleft 
in  the  palate;  Z,,  L,  right  and  left  lips  respectively.  Note  the  cleft  between  these 
rudimentary  lips  and  the  central  portion  of  the  lip,  P,  covering  the  intermax- 
illary bone;  T,  tongue.  This  photograph  was  taken  while  the  child  was 
crying  (Eisendrath). 

going  up  into  the  nose.  Plaster-of-Paris  should  always 
be  used  in  taking  the  impression.  From  the  impression 
a  cast  is  made,  and  the  obturator  constructed  just  as  in 
the  case  of  a  vulcanite  or  metal  denture.  The  obturator 
is  kept  in  place  in  the  mouth  by  means  of  clasps.  In 
using   clasps   it   is   always   advisable   to   attach   them 


MALFORMATIONS   OF   THE  JAWS  233 

to  teeth  that  are  not  quite  opposite  to  one  another. 
Thus  it  is  well  to  clasp  a  first  molar  on  one  side  of  the 
mouth,  and  a  second  bicuspid  on  the  other.  This 
keeps  the  piece  firm  and  prevents  rocking.  Where  a 
cleft  in  the  soft  palate  is  to  be  filled,  the  part  of  the  ob- 
turator representing  the  soft  palate  may  be  made  of 
hard  rubber  and  attached  to  the  front  piece  by  a  hinge, 
which  allows  accommodation  to  the  movements  of  swal- 
lowing; or  the  back  piece  may  be  made  of  soft  rubber. 
This  piece  is  first  built  on  to  the  anterior  portion  in  wax, 
and  its  proper  size  and  shape  are  obtained  by  trying  it 
in  the  mouth  several  times,  trimming  it  off  until  perfect 
adaptation  is  obtained. 

Obturators  are  used  not  only  in  the  treatment  of 
acquired  cleft-palate,  but  are  required  in  cases  of  inop- 
erable congenital  cleft-palate. 

2.  Congenital  Cleft-palate. — In  order  to  comprehend 
the  congenital  formation  of  cleft-palate  it  is  necessary 
to  understand  something  of  the  development  of  the 
maxillary  bonesr  The  maxilla  is  developed  from 
two  processes — the  lateral  process,  or  true  maxilla,  and 
the  anterior  nasofrontal  process,  or  premaxillary  bone. 
Under  normal  conditions  the  premaxillai  of  the  two  sides 
unite  at  about  the  fortieth  day  of  embryonic  Hfe  to  form 
the  intermaxillary  bone,  which  in  turn  becomes  joined 
to  the  lateral  processes  or  true  maxilla3.  These  also 
unite  with  each  other  in  the  median  line  behind  the 
intermaxillary  bone.  Under  abnormal  conditions  these 
processes  may  fail  to  unite,  resulting  in  the  formation 
of  single  or  double  cleft-palate.  In  sin^e  cleft-palate 
the  cleft  passes  between  the  intermaxillary  bone  and  one 
of  the  true  maxillae,  and  then  is  continued  backward 


234  SPECIAL   SURGERY 

between  the  palatal  processes  of  the  maxillce  and  the 
horizontal  processes  of  the  palate  bones.  It  may  or  may 
not  involve  the  soft  palate,  but  usually  does.  It  is 
thus  seen  that  the  cleft  anteriorly  is  to  one  side  of  the 
median  line,  while  posteriorly  it  runs  in  the  median  line. 
In  rare  cases  the  cleft  is  due  to  failure  on  the  part  of  the 
two  premaxilla)  to  unite,  and  here  the  opening  is  in  the 
median  line  anteriorly  as  well  as  posteriorly. 

In  double  cleft-palate  there  is  a  cleft  on  either  side  of 
the  intermaxillary  bone,  the  two  clefts  joining  poste- 
riorly to  this  bone  to  form  a  single  cleft  which  passes 
between  the  two  true  maxilla?  and  between  the  horizontal 
processes  of  the  palate  bones.  From  this  it  will  be  seen 
that  the  opening  in  double  cleft-palate  is  Y-shaped, the 
divergent  arms  of  the  Y  embracing  the  intermaxillary 
bone.  This  description  is  somewhat  diagrammatic, 
as  the  small  size  of  the  intermaxillary  bone  and  distor- 
tion of  the  parts  sometimes  make  it  difficult  to  follow 
out  the  course  of  the  cleft  according  to  the  description. 
Congenital  cleft-palate  may  be  complete,  that  is,  em- 
bracing both  hard  and  soft  palate,  or  incomplete,  involv- 
ing the  hard  palate  or  the  soft  palate  only.  It  may  or 
may  not  be  associated  with  harelip. 

Causes  of  Congenital  Cleft-palate. — There  are  many 
theories  explaining  why  the  bones  do  not  unite.  Accord- 
ing to  one  theory,  about  the  sixth  week  of  embryonic 
life,  through  fright  to  the  mother  or  some  other  cause, 
nourishment  to  the  parts  is  cut  off  or  diminished,  which 
prevents  them  from  uniting.  Mechanical  theory:  The 
lower  jaw,  being  formed  first,  influences  the  shape  of 
the  upper  jaw,  and,  owing  to  some  undue  pressure  within 
the  uterus,  is  forced  between  the  formative  processes 


MALFORMATIOXS   OF  THE  JAWS  235 

of  the  upper  jaw,  and  thus  prevents  their  union.  This 
theory  is  borne  out  by  the  fact  that  in  cases  of  cleft- 
palate  the  alveolar  ridge  of  the  upper  jaw  is  outside  that 
of  the  lower  jaw,  while  under  normal  conditions  it  is 
inside  it.  This  theory  is  further  borne  out  by  the  fact 
that  after  operation  for  cleft-palate  the  upper  jaw,  when 
its  two  halves  are  brought  together,  is  not  too  small, 
this  proving  that  the  cleft  is  not  due  to  lack  of  tissue 
(Cryer). 

Treatment. — The  treatment  of  congenital  cleft-palate  is 
either  mechanical  or  operative.  Mechanical  treatment 
is  resorted  to  when  operative  treatment  is  not  indicated, 
i.  €.,  when  a  patient  with  a  wide  cleft  has  been  allov/ed 
to  reach  a  mature  age.  The  best  age  for  operation  is 
as  soon  after  the  birth  of  the  child  as  it  has  become  used 
to  its  surroundings,  provided  it  be  well  nourished—/,  c, 
before  the  age  of  six  months.  The  bones  at  this  early 
period  are  not  thoroughly  calcified,  and  can,  therefore, 
easily  be  brought  together.  The  sooner  the  operation 
is  performed  also,  the  better  for  the  general  health  and 
nourishment  of  the  child,  as  it  cannot  suck  with  a  cleft- 
palate.  The  teeth  at  this  age  have  not  erupted,  and  the 
parts  are,  therefore,  more  accessible  than  if  the  teeth 
were  in  position.  The  child  has  not  yet  learned  to  talk, 
and  has  no  mispronunciation  to  correct. 

The  following  is  a  brief  description  of  the  Brophy 
operauion,  which  is  suitable  in  a  large  number  of  cases: 
The  cheek  is  raised,  and  a  silk  suture  is  inserted  into 
the  substance  of  the  bone  just  behind  the  malar  process 
and  carried  out  on  the  opposite  side.  Care  must  be 
taken  to  place  the  suture  above  the  palatal  plate  of  the 
bone.     This  suture  is  then  replaced  by  one  of  silver  wire, 


236     ■  SPECIAL   SURGERY 

which  may  be  doubled,  if  necessary.  Anterior  to  this 
wire  another  silver  wire  is  inserted  and  carried  through 
the  substance  of  the  bone  above  the  palatal  plates,  and 
out  through  the  other  side,  at  a  position  corresponding 
to  the  place  of  entrance.  The  next  step  is  to  take  two 
lead  plates  molded  to  fit  the  parts,  one  on  either  side  of 
the  outer  portion  of  the  upper  jaw,  each  long  enough  to 
pass  beyond  the  points  of  exit  of  the  wire  sutures,  so 
that  they  will  pass  through  it.  Each  plate  is  provided 
with  holes  through  which  pass  the  two  ends  of  the  wires 
as  they  emerge  on  each  side.  The  bones  are  now  pressed 
together  and  held  in  position  by  twisting  the  ends  of 
the  wires.  After  approximation  of  the  parts,  additional 
sutures,  if  necessary,  are  inserted  in  the  median  line  of 
the  mouth.  The  abrasions  caused  by  the  metal  plates 
are  usually  very  slight,  and  need  not  cause  any  anxiety. 
They  may  remain  in  place  six  or  eight  weeksx  After 
closure  of  the  cleft  the  palate  will  not,  as  a  rule,  be  con- 
tracted to  an  abnormal  extent.  The  teeth  will  also 
generally  be  found  to  erupt  and  occlude  normally  with 
those  of  the  lower  jaw.  If  this  does  not  occur,  the  irreg- 
ularity must  be  corrected. 

In  some  cases  of  cleft-palate,  where  the  intermaxillary 
bone  is  turned  up  and  attached  to  the  septum  of  the 
nose  in  front,  it  is  necessary  to  remove  it  altogether. 
In  this  case  the  incisor  teeth,  both  temporary  and  per- 
manent, will  be  lost,  as  their  germs  are  contained  in  the 
intermaxillary  bone. 

The  Brophy  operation  is  not,  as  a  rule,  suitable  for 
cases  over  six  months  old,  as  the  bones  by  this  time  are  not 
sufficiently  pliable  to  be  pressed  together.  In  cases  over 
this  age,  and  in  which  the  cleft  is  very  wide,  a  flap  oper- 


MALFORMATIONS   OF  THE  JAWS  237 

ation  is  indicated.  The  Brophy  flap  operation  is  made 
by  loosening  a  flap  of  mucous  membrane  from  the  bone  on 
either  side  of  the  cleft,  and  uniting  the  free  edges  in  the 
median  line  with  silver-wire  sutures,  prevented  from 
cutting  out  by  lead  plates.  The  Lane  operation  is  as 
follows:  A  large  flap  of  mucous  membrane  is  dissected 
from  the  hard  palate  on  one  side  of  the  cleft,  being  still 
attached  to  the  bone  on  the  side  nearest  the  cleft. 
This  is  turned  completely  over,  with  its  raw  edge  down- 
ward, and  its  free  edge  tucked  under  the  mucous  mem- 
brane that  has  been  lifted  from  the  boije  on  the  opposite 
side  of  the  cleft.  The  flaps  are  now  secured  in  place 
by  silk  sutures.  The  raw  surface  in  time  is  covered  over 
with  epitheHum.  In  the  flap  operations  no  attempt  is 
made  to  bring  the  bones  together. 

In  inoperable  cases  of  cleft-palate  obturators  and  vela 
may  be  made,  just  as  in  cases  of  acquired  cleft-palate. 

Harelip 
Harelip  (Figs.  55  and  56)  is  a  congenital  cleft  or  fissure 
in  the  lip,  usually  the  upper.  It  is  due  to  the  same  causes 
as  congenital  cleft-palate,  i.  c,  a  failure  to  unite  on  the 
part  of  the  developmental  processes  in  the  embryo. 
It  may  occur  with  or  without  cleft-palate,  and  cleft- 
palate  may  occur  without  harelip.  The  fissure  is  gen- 
eraUy  situated  at  a  point  opposite  the  space  between  the 
canine  and  lateral  incisor  teeth.  Harelip  may  be  single, 
with  a  cleft  only  on  one  side  of  the  lip,  or  double,  in  which 
there  is  a  cleft  on  both  sides  of  the  median  line.  Occa- 
sionally the  fissure  may  be  situated  in  the  median  line, 
or  between  the  central  and  lateral  incisors. 

Treatment.— YJhcre  the  fissure  is  only  slight,  the  treat- 


238 


SPECIAL   SURGERY 


ment  consists  in  paring  the  edges,  bringing  them  together, 
and  holding  them  in  place  with  interrupted  silk  or  horse- 


Pig.  55. — Harelip  (Campbell). 


hair  sutures.     The  sutures  should  pass  down  as  far  only 
as  the  mucous  membrane,  and  not  through  it,  thus  avoid- 


Fig.  56. — Double  harelip  (before  operation)  (Grant). 

ing  infection  as  much  as  possible.     In  applying  the  dress- 
ing, direct  pressure  must  not  be  brought  to  bear  on  the 


MALFORMATIONS   OF   THE  JAWS  239 

line  of  suture.  To  prevent  this,  small  rolls  of  gauze  are 
placed  one  on  either  side  of  the  cleft,  and  the  dressing 
of  iodoform  gauze  laid  between  these.  The  dressing  is 
secured  in  place  with  a  strip  of  adhesive  plaster.  The 
chances  of  infection  are  greatly  lessened  by  applying 
Whitehead's  varnish  to  the  line  of  suture,  and  if  this  is 
done  a  large  gauze  dressing  can  be  dispensed  with.  The 
sutures  should  remain  in  five  or  six  days. 

When  the  cleft  in  the  lip  is  a  wide  one  the  operator 
must  use  his  ingenuity  in  cutting  flaps  to  obtain  sufficient 
tissue  to  fill  in  the  space.  It  is  wise,  if  possible,  to  get 
tissue  a  little  in  excess  of  the  amount  needed,  as  it  usually 
contracts  later. 

In  a  combined  case  of  harelip  and  cleft-palate  the 
palate  should,  if  possible,  be  operated  upon  first.  By 
doing  this  the  operator  has  better  access  to  the  palate 
than  if  the  fissure  in  the  lip  were  closed  first.  Another 
reason  is  that  it  is  more  important  for  the  nourishment 
of  the  patient  that  the  cleft  in  the  palate  should  be  closed 
than  that  in  the  lip.  The  cleft-palate  can  be  closed  only 
by  an  operation  early  in  life,  while  the  harelip  can  be 
remedied  at  any  time. 

Injuries  During  Childbirth 

Inferior  Prognathism. — By  this  term  is  meant  a 
projection  of  the  mandible,  causing  an  overlapping  of  the 
lower  front  teeth  in  advance  of  the  upper.  Observations 
have  shown  that  this  deformity  is  not  always  merely  a 
malposition  of  the  teeth,  but  is  often  primarily  due  to  a 
forward  position  of  the  entire  mandible,  and  that  there  is 
a  subluxation  of  the  condyle  of  the  mandible  on  to  the 
eminentia  articularis  of  the  temporal  bone,  the  condyle 


240  SPECIAL    SURGERY 

assuming  this  position,  instead  of  being,  back  in  the  ante- 
rior portion  of  the  glenoid  fossa.  Examination  of  a  skull 
in  which  inferior  prognathism  exists  will  show  this,  and 
the  :v-rays  will  show  it  in  living  subjects.  Many  of  these 
cases  are  known  to  have  been  breech  presentations  at 
birth.  It  is  estimated  that  breech  presentations  occur 
in  about  3  per  cent,  of  all  cases  of  labor.  In  various 
methods  employed  for  deUvery  of  the  after-coming  head 
in  breech  presentations  the  finger  of  the  accoucher  is 
placed  in  the  child's  mouth  to  make  strong  traction  on 
the  chin,  and  it  is  reasonable  to  suppose  that  subluxation 
of  the  mandible  may  be  caused  by  this  procedure,  fol- 
lowed by  inferior  prognathism. 

Treatment. — The  attending  physician  in  a  case  of 
labor  should  examine  the  jaws  of  the  child,  and  if  the 
deformity  has  been  produced,  recognized  by  undue 
projection  of  the  chin,  to  correct  it  immediately,  pushing 
the  condyles  back  into  position.  If  allowed  to  remain,  it 
becomes  impossible  to  reduce  the  dislocation  later. 
When  seen  later  in  life,  a  case  of  this  kind  may  be  bene- 
fited by  operation,  the  rami  of  the  mandible  being 
divided,  and  the  whole  bone  being  carried  backward 
the  required  distance.  Before  the  operation  intermaxil- 
lary spHnts  should  be  made  to  hold  the  jaw  in  its  correct 
relation . 

Another  deformity  of  the  jaw  occasionally  seen  in 
adults  is  absence  of  the  normal  angle  of  the  mandible. 
The  ramus  in  this  case  is  nearly  in  a  straight  line  with 
the  body  of  the  jaw,  and  the  result  is  that  only  the  back 
teeth  occlude,  leaving  a  space  between  the  anterior  upper 
and  lower  teeth  when  the  mouth  is  shut.  Absence  of 
normal  acuteness  of  the  angle  of  the  lower  jaw  may  also 


MALFORMATIONS  OF  THE  JAWS  24 1 

be  associated  with  the  condition  of  forward  bite  of  the 
lower  teeth,  as  just  described.  It  is  not  an  obliteration 
of  the  angle  so  much  as  some  interference  with  develop- 
ment, because  there  is  scarcely  any  angle  at  birth  in  the 
normal  subject.  It  has  been  shown  that  this  deformity 
followed  cases  of  difficult  labor  in  which  the  jaws  were 
subjected  to  undue  pressure,  or  in  which  the  forceps 
were  used.  Special  care  in  the  appHcation  of  the  forceps 
may  prevent  the  deformity.  When  seen  in  later  life, 
it  may  be  corrected  by  operation. 

Review  Questions 

Define  cleft-palate. 

Give  the  etiology  and  treatment  of  acquired  cleft-palate. 

Describe  the  different  forms  of  congenital  cleft-palate,  with  theories 
as  to  production. 

Give  the  treatment  of  congenital  cleft-palate. 

What  is  the  best  age  for  operation  on  cleft-palate?     Give  reasons. 

Describe  the  Brophy  operation  for  cleft-palate. 

Describe  harelip  and  give  treatment. 

In  a  case  of  harelip  combined  with  cleft-palate,  which  should  be  oper- 
ated upon  first?     Give  reasons. 

16 


CHAPTER  XXVI 

FRACTURES 

A  fracture  is  a  solution  in  the  continuity  of  a  bone,  the 
result  of  trauma,  disease,  or  muscular  action. 

Fractures  are  divided  into — (i)  Greenstick;  (2) 
simple;  (3)  compound;  (4)  comminuted. 

1.  A  greenstick  fracture  is  an  incomplete  fracture  which 
occurs  in  children,  in  which  the  fractured  ends  are  joined 
together  by  unbroken  fibers  of  bone  resembling  a  broken 
green  stick.  The  peculiar  character  of  these  fractures  is 
due  to  the  incomplete  calcification  of  the  bones  of 
children. 

2.  A  simple  fracture  is  one  in  which  the  break  occurs 
without  infliction  of  an  external  wound  which  communi- 
cates with  the  ends  of  the  fractured  bone. 

3.  A  compound  fracture  is  one  in  which  the  fractured 
bone  communicates  with  the  external  air  through  a 
wound.     It  is  also  known  as  an  open  fracture. 

4.  A  comminuted  fracture  is  one  in  which  the  bone  is 
broken  into  numerous  small  fragments. 

The  general  principles  of  treatment  of  a  fracture 
consist  in  reducing  the  fracture,  i.  e.,  bringing  the  frac- 
tured ends  of  the  bone  into  correct  apposition,  and  hold- 
ing them  in  position  by  splints  and  bandages  until 
reunion  takes  place.  In  a  compound  fracture  these 
procedures  are  to  be  supplemented  by  disinfection  of 
the  wound. 

243 


FRACTUHES  243 

The  special  fractures  that  will  be  taken  up  in  detail 
are: 

1.  Fractures  of  the  upper  jaw,  comprising  the  maxilla, 
and  sometimes  involving  also  the  palate  and  malar  bones 
and  the  zygomatic  arch. 

2.  Fractures  of  the  lower  jaw  or  mandible. 
Fractures    of    the    upper    jaw    bones   are   rare.     A 

frequent  method  of  production  when  bicycle  riding  was 
popular  was  by  sudden  arrest  of  the  machine,  and  pro- 
jection of  the  rider  over  the  handle-bars.  Cases  are  on 
record  of  complete  fracture  of  the  upper  jaw  through 
the  floor  of  the  orbits  on  each  side.  Usually  only  a 
portion  of  the  alveolar  process  is  fractured,  and  this 
may  occur  by  blows,  during  the  extraction  of  a  tooth, 
or  from  a  bullet  wound.  In  extraction  of  the  upper 
third  molar  the  tuberosity  may  be  broken  off.  A  bullet 
or  the  end  of  a  blunt  instrument  may  pass  through  the 
roof  of  the  mouth,  perforating  the  hard  palate.  Owing 
to  the  absence  of  attachment  of  powerful  muscles  to 
the  upper  jaw  great  displacement  of  the  fragments  is 
uncommon. 

Fractures  of  the  Mandible 
These  make  up  the  great  bulk  of  fractures  of  the  jaw 
bones.     They  are  usually  compound,  the  fractured  ends 
of    the  bones   communicating  with  the   mouth  cavity 
through  a  laceration  of  the  mucous  membrane. 

Etiology. — Fractures  of  the  mandible  may  be  caused 
by  kicks,  blows,  bullet  wounds,  necrosis  of  the  bone, 
or  muscular  action.  It  is  often  difficult  to  obtain  a 
clear  history  of  the  injury,  as  the  patient  is  often  intox- 
icated at  the  time  of  its  reception. 

Seat  of  Fracture.— The  most  frequent  single  seat  of 


244  SPECIAL   SURGERY 

fracture  is  the  region  of  the  mental  foramen.  The 
bone  is  weakened  here  by  the  mental  foramen  and  by 
the  peculiarly  attenuated  internal  structure  of  the 
bone  at  this  place,  which  is  one  of  the  fixed  points  from 
which  growth  extends.  At  this  position  also  is  the 
middle  of  the  curve  in  the  body  of  the  jaw,  and  finally 
the  large  socket  of  the  canine  tooth  is  situated  in  this 
region.  Fractures  may  also  occur  in  the  region  of  the 
angle,  between  the  angle  and  the  mental  foramen,  and 
at  the  symphysis  menti.  Fractures  of  the  ramus,  the 
condyloid  and  coronoid  processes,  are  rare,  owing  to  the 
protection  afforded  by  overlying  muscles.  Fracture  of 
the  condyloid  process  is  usually  produced  by  a  blow 
on  the  opposite  side  of  the  chin.  When  a  fracture 
occurs  in  the  region  of  the  angle  the  direction  of  the 
break  is  anterior  from  below  upward,  generally  at 
an  angle  of  about  60  degrees  from  the  horizontal.  The 
lower  jaw  is  often  broken  in  more  than  one  place,  the 
fractures  usually  occurring  on  opposite  sides.  The 
fractures  may  occur  at  corresponding  places  on  the  two 
sides,  or  at  different  places,  according  to  the  direction  of 
the  breaking  force.  A  common  double  fracture  is  one  in 
which  the  bone  is  broken  near  the  mental  foramen  on  one 
side  and  through  the  angle  on  the  other.  Comminution 
may  occur  when  the  trauma  is  of  exceptional  severity. 

Owing  to  early  ossification,  greenstick  fractures  of 
the  mandible  are  rare.  One  case  of  fracture  or  separa- 
tion at  the  symphysis  menti  by  the  obstetric  forceps 
during  parturition  has  been  reported.^ 

Complications. — Fractures  of  the  mandible  being 
usually  compound,  the  commonest  complication  is 
infection  of  the  intramandibular  and  perimandibular 
^  Ivy,  R.  H.,  Univ.  of  Pa.  Med.  Bull.,  1907. 


FRACTURES  24$ 

tissue,  which  may  lead  to  cellulitis,  suppuration  and  ab- 
scess, necrosis  of  bone,  sinus  formation,  and  delayed  or 
non-union.  Infection  of  the  tissues  after  fracture  is 
much  less  common  than  one  would  suppose  in  view  of 
the  fact  that  the  seat  of  fracture  immediately  becomes 
bathed  in  saliva  loaded  with  many  varieties  of  pathogenic 
bacteria.  From  this  it  is  inferred  that  the  saliva  exerts 
some  restraining  power  over  the  organisms,  lessening 
their  virulence.  It  is  generally  in  neglected  cases,  in 
persons  of  low  vitality,  and  in  jaws  previously  infected 
by  diseased  teeth  that  abscesses  occur.  Abscesses 
following  infection  at  the  seat  of  fracture  may  open 
directly  over  the  point  of  injury,  or  may  burrow  under 
the  fascia  and  open  on  the  neck  at  some  distant  point. 
Persistent  sinuses  often  remain,  due  to  the  presence  of 
necrosed  bone. 

In  many  cases  teeth  become  loosened  at  the  seat  of 
fracture  either  by  the  traumatism  or  by  subsequent 
infection,  or  roots  of  teeth  may  be  fractured  In  repair 
of  the  fractured  bone  filaments  of  the  inferior  dental 
nerve  may  be  caught  in  the  callus  or  the  main  trunk 
pressed  upon,  causing  neuralgia.  Fracture  is  frequently 
followed  by  anesthesia  or  numbness  of  the  lips  and  skin 
covering  the  chin,  owing  to  rupture  or  laceration  of  the 
inferior  dental  nerve,  which  supplies  the  region  through 
its  mental  branch.  The  interference  with  sensation  is 
only  temporary,  however,  as  regeneration  nearly  always 
follows.  Delayed  and  non-union  are  common  in  neg- 
lected cases.  Infection  and  abscess  formation  are 
undoubtedly  a  cause  of  delayed  and  non-union  of  frac- 
tures of  the  mandible,  but  a  far  more  common  cause 
lies  in  imperfect  reduction  and  fixation  of  the  fragments. 


246  SPECIAL   SURGERY 

Delayed  union  is  more  frequently  seen  in  double  frac- 
tures, in  which  immobilization  is  more  difficult  than 
in  single  fracture.  Among  possible  complications  is 
pneumonia  due  to  inhalation  of  septic  material  from  the 
mouth.  T.  T.  Thomas  reports  a  case  of  Ludwig's  angina 
following  fracture  due  to  a  gunshot  wound. ^ 

Fracture  or  solution  of  continuity  of  the  lower  jaw  may 
result  from  a  primary  weakening  of  the  bone  by  disease, 
followed  by  necrosis.  In  other  long  bones  of  the  body 
experience  shows  that  while  new  bone  may  be  formed 
to  replace  necrotic  bone,  union  after  necrosis  with  frac- 
ture practically  never  takes  place.  This  applies  only 
to  cases  in  which  fracture  was  primarily  due  to  disease 
and  not  to  trauma.  In  the  mandible  this  rule  does  not 
hold  good.  There  are  several  instances  recorded  in 
which  regeneration  of  new  bone  in  the  place  of  that  lost 
by  necrosis  occurred  after  a  complete  solution  of  conti- 
nuity; the  result  was  perfect  union  and  subsequent 
restoration  of  function. 

Symptoms  and  Diagnosis. — Fracture  of  the  mandible 
has  the  symptoms  common  to  fractures  of  other  bones, 
viz.,  sharp  pain,  crepitus,  or  grating  on  rubbing  the  ends 
together,  preternatural  mobility,  deformity,  indicated 
by  malocclusion  of  the  teeth,  swelling,  and  impaired 
function.  The  pain  and  tenderness  are  much  greater 
than  any  lesser  injury.  When  the  fracture  occurs  in 
the  portion  of  the  jaw  occupied  by  teeth,  the  line  of 
the  teeth  may  be  irregular,  the  teeth  anterior  to  the  break 
lying  on  a  lower  level  than  those  posterior  to  it.  This 
is  due  to  the  fact  that  the  posterior  fragment  is  held  up 
in  position  by  the  elevator  muscles,  while  the  depressor 
^  Annals  of  Surgery. 


FRACTURES 


247 


muscles  and  gravity  cause  the  anterior  fragment  to  drop. 
By  grasping  one  of  the  fragments  in  each  hand  they 
can  be  made  to  move  up  and  down  one  upon  the  other, 
which  is  indicated  by  the  adjacent  teeth  interchanging 


Mk.  57.— Ka'li<if,'rai)h  showiiiR  fracture  at  angle  of  mandible  (after  Cryer). 

levels.  Crepitus  is  also  elicited  in  this  way.  In  frac- 
tures of  the  angle  or  ramus  behind  the  insertion  of  the 
masseter  little  or  no  deformity  occurs,  as  the  anterior 
fragment  is  then  held  up  by  this  muscle,  making  diagnosis 


248  SPECIAL   SURGERY 

difficult.  In  these  cases  the  x-ray  is  useful  in  deciding  the 
nature  of  the  injury.  In  all  cases  the  x-ray  is  valuable  in 
determining  the  direction  of  the  fracture,  injuries  to  roots 
of  teeth,  involvement  of  teeth  in  the  fracture,  and  posi- 
tion of  the  fragments  after  reduction  (Fig.  57). 

Fracture  of  the  condyloid  process  may  be  diagnosed  by 
history  of  a  blow  on  the  opposite  side  of  the  chin,  swelling 
and  pain  in  front  of  the  ear,  limitation  of  motion,  and 
deviation  of  the  chin  toward  the  affected  side  when  the 
mouth  is  closed.  It  is  sometimes  difficult  to  obtain  a 
good  x-ray  picture  showing  the  injury.  Fracture  at  this 
point  is  sometimes  followed  by  ankylosis,  though  in  the 
experience  of  the  writer  the  fragments  in  untreated  cases 
usually  unite  in  malposition,  leaving  deformity  without 
ankylosis.     (Annals  of  Surgery,  May,  191 5. 

Treatment. — Fractures  of  the  mandible  will  be  dealt 
with  first. 

The  rules  for  treatment  of  fractures  in  general  apply 
to  fractures  of  the  mandible,  namely,  reduction  and 
fixation  of  the  fragments  until  firm  union  takes  place. 
But  the  peculiar  shape  and  position  of  the  bone,  and 
its  close  relation  to  the  bacteria-laden  mouth,  render 
necessary  important  modifications  and  special  methods 
of  treatment.  Thus  the  danger  of  infection  is  greatly 
increased  in  cases  in  which  no  attention  is  paid  to  the 
hygiene  of  the  oral  cavity.  Therefore,  whenever  possible 
before  inserting  splints  or  applying  bandages,  tartar 
should  be  removed  from  the  teeth,  suppurating  roots 
extracted,  and  the  mouth  well  washed  out  with  an 
antiseptic  solution.  A  very  satisfactory  antiseptic 
and  deodorant  is  a  i  :  2000  solution  of  potassium  per- 
manganate.    Throughout  the  period  of  treatment  the 


FRACTURES  .  249 

mouth  should  be  syringed  with  this  twice  a  day.  Hav- 
ing got  the  mouth  as  clean  as  possible,  the  fragments 
are  to  be  reduced  and  fixed  in  position.  The  method 
used  depends  on  the  seat  of  fracture,  accessibility  of 
suitable  appliances,  the  presence  or  absence  and  the 
number  of  teeth,  the  amount  of  displacement  of  the 
fragments,  and  the  presence  of  compHcations.  In  many 
cases  where  the  teeth  are  good  and  the  upper  and  lower 
teeth  occlude  well,  and  particularly  where  no  appliances 
are  at  hand  for  making  sphnts,  good  results  are  obtained 
by  bringing  the  lower  teeth  in  correct  occlusion  with 
the  upper,  and  holding  them  there  with  a  firm  Barton 
bandage.  Additional  stabihty  may  be  given  to  the 
dressing  by  a  pasteboard  cup  molded  to  fit  the  chin, 
and  padded  with  cotton  before  being  applied. 

It  is  better  not  to  reduce  the  fracture  completely  by 
bringing  the  upper  and  lower  teeth  into  absolute  occlu- 
sion, but  to  wait  one  or  two  days  until  the  swelling  and 
extreme  tenderness  of  the  face  pass  away.  After 
that,  however,  the  teeth  must  be  held  together  by  the 
bandage.  The  bandage  is  Hable  to  work  loose  by  stretch- 
ing after  a  few  days.  To  avoid  displacement  of  the  frag- 
ments by  removing  it,  the  bandage  may  be  tightened  by 
placing  pads  of  muslin  between  it  and  the  vertex  of  the 
skull.  The  bandages  used  in  these  dressings  should 
always  be  of  muslin  and  not  of  gauze,  and  they  should 
have  been  previously  stretched,  if  possible.  In  applying 
the  Barton  bandage,  great  care  must  be  used  to  see 
that  the  fragments  are  in  good  position  and  that  the 
teeth  occlude  correctly,  as  it  is  very  easy  to  exert  too 
much  pressure  upon  one  particular  region,  drawing  the 
bone  out  of  position  at  this  place.     To  feed  the  patient 


250  SPECIAL  SURGERY 

it  is  not  necessary  to  extract  a  tooth,  as  recommended  by 
some  authors.  He  can  in  every  case  be  fed  on  liquids 
through  a  tube,  the  food  passing  in  between  the  teeth, 
and  through  the  spaces  behind  the  third  molars.  In  un- 
complicated cases  treated  by  this  method  firm  union 
between  the  fragments  takes  place  in  from  four  to  five 
weeks. 

In  some  cases  of  this  character  a  very  satisfactory 
way  of  adding  stability  to  the  dressing  is  by  placing  over 
the  Barton  bandage  another  of  gauze  incorporated  with 
plaster-of -Paris.  When  the  plaster  sets,  the  dressing  can 
be  cut  through  on  each  side,  and  the  free  ends  trimmed 
off  until  it  fits  snugly.  The  dressing  can  then  be  fast- 
ened securely  with  strips  of  adhesive  plaster.  This 
dressing  has  the  advantage  of  being  easily  removed  when 
necessary. 

Gilmer's  Method. — In  other  cases,  where  the  teeth  and 
occlusion  are  good,  after  removing  deposits  and  getting 
the  mouth  as  clean  as  possible,  the  fragments  may  be 
maintained  in  proper  apposition  by  holding  the  lower 
teeth  in  correct  relation  to  the  upper  by  means  of  brass 
wire  ligatures  passed  around  two  or  three  teeth  on  each 
side  of  the  fracture,  these  ligatures  being  fastened  to  simi- 
lar ones  applied  to  corresponding  teeth  of  the  upper  jaw. 
After  twisting  the  wires  together  and  cutting  them  off 
the  sharp  ends  may  be  covered  with  softened  gutta- 
percha to  prevent  irritation.  This  method  may  some- 
times be  employed  to  advantage  in  maintaining  correct 
occlusion  of  the  teeth  in  fracture  of  the  angle  or  ramus. 

Splints. — Many  splints  have  been  devised  for  these 
fractures,  including  interdental  vulcanite  spHnts,  metal 
maxillomandibular  splints,  metal  caps  fitting  over  the 


FRACTURES  2$  I 

teeth  adjacent  to  the  fracture,  metal  bands  around  the 
teeth,  and  silver  plates  attached  to  the  bone  by  screws. 
Metal  bands  about  the  teeth,  as  advocated  by  Angle, 
can    be    used    successfully    in    certain    cases.     Opera- 
tive treatment  by  wiring  the  bone  or  attaching  silver 
plates  by  screws  has  not  been  successful,  as  a  rule,  as  the 
parts  cannot  be  sufficiently  immobilized,  and  the  wires 
or  plates  through  infection  or  mobility  nearly  always 
work  loose  before  union  of  the  bone  has  taken  place. 
The  vulcanite  interdental  splint,  which  fixes  the  jaws  with 
a  space  between  the  upper  and  lower  teeth,  is  sometimes 
used  in  fractures  occurring  in  the  portion  of  the  mandible 
occupied  by  teeth.     This  splint  is  particularly  contra- 
indicated   in   fracture   posterior   to   the   teeth,    as   the 
"  open-bite  "  position  produced  by  it  does  not  maintain 
the  fragments  in  correct  relation,  a  V-shaped  space  being 
formed  at  the  seat  of  fracture,  which  fills  up  by  the 
process  of  repair,  thus  preventing  the  front  teeth  from 
coming  together  after  removal  of  the  splint.     Vulcanite 
splints  are  also  uncleanly  and  cumbersome,  and  should 
be  relegated  to  the  museum.     For  any  fracture  occur- 
ring in  the  region  of  the  teeth  by  far  the  most  comfortable, 
hygienic,  and  least  cumbersome  splint  is  one  made  of 
a  metal  cap  or  bridge  fitting  over  several  teeth  adjacent 
to  the  seat  of  fracture.      The  chief  advantage  of  his 
device  is  that  it  firmly  fixes  the  fragments  and  at  the 
same  time   allows  the  patient   to   open  and  close  his 
mouth.     It  is  made  as  follows:  A  plaster-of-Paris  im- 
pression  is   taken   of   the   teeth  of   the   fractured  jaw 
before  reduction,  and  also  one  of  the  upper  teeth,  and 
casts  made  from  these.     The  lower  cast  will  represent 
the  teeth  in  their  relation  after  fracture.     The  cast  is 


252  SPECIAL   SURGERY 

now  cut  through  with  a  saw  at  the  place  corresponding 
to  the  fracture,  and  the  two  portions  arranged  so  that 
the  teeth  will  occlude  correctly  with  those  of  the  upper 
jaw,  i.  e.,  will  be  as  they  were  before  fracture  occurred. 
The  two  portions  of  the  cast  are  cemented  together, 
zinc  dies  are  made,  and  a  cap  of  German  silver  or  of 
gold  is  swaged.  The  cap  should  take  in  two  or  three 
teeth  on  each  side  of  the  fracture.  The  fragments  can 
now  be  reduced,  and  the  splint  cemented  in  place  over 
the  teeth.  It  is  wise  to  reinforce  the  splint  with  a 
Barton  bandage  until  the  cement  thoroughly  hardens. 
This  splint  is  suitable  in  cases  where  there  are  several 
firm  teeth  immediately  on  each  side  of  the  seat  of  frac- 
ture. 

The  mandihulomaxillary  metal  splint  consists  of  two 
portions,  one  covering  the  lower  and  the  other  the  upper 
teeth,  the  two  parts  being  soldered  together.  By  this 
splint  the  jaws  are  fixed  together  with  the  bite  closed, 
in  contrast  to  the  vulcanite  interdental  spHnt.  Thus 
it  can  be  used  in  fractures  of  the  angle  of  the  mandible 
without  producing  a  V-shaped  space  at  the  seat  of  frac- 
ture, which  is  formed  when  the  jaws  are  fixed  with  the 
bite  open.  In  these  fractures  at  or  behind  the  angle  the 
essential  point  is  to  fix  the  anterior  fragment  in  its 
normal  relation  with  the  upper  jaw.  The  posterior 
fragment  will  take  care  of  itself,  as  it  is  not  displaced  to 
any  great  degree.  The  mandihulomaxillary  splint  is 
made  of  gold  or  of  German  silver  in  the  same  way  as  the 
metallic  splint  for  the  lower  teeth,  except  that  a  cap 
is  also  made  to  fit  over  the  upper  teeth  and  the  two 
soldered  together  after  grinding  the  occluding  surfaces 
of  the  metal  to  obtain  close  apposition  of  the  upper  and 


FRACTURES  253 

lower  teeth.  The  patient  receives  nourishment  through 
the  spaces  behind  the  third  molar  teeth.  This  splint 
can  be  used  in  any  case  of  fracture  where  there  is  a  suffi- 
cient number  of  sound  teeth,  and  is  far  superior  to  the 
vulcanite  splint,  being  more  cleanly  and  less  bulky. 
Before  inserting  any  splint  the  same  precautions  of 
cleansing  the  mouth  must  be  observed  as  in  cases  treated 
by  the  bandage  alone.  Many  cases  occur  in  which  the 
teeth  are  very  poor,  and  naturally  they  are  the  most 
difficult  to  treat.  Sometimes  a  satisfactory  splint  cannot 
be  made  owing  to  absence  or  poor  quality  of  the  teeth, 
and  we  have  to  rely  on  the  bandage  and  external 
pasteboard  cup.  In  edentulous  mouths  mandibulo- 
maxillary  splints,  made  from  impressions  of  the  gums, 
sometimes  bring  about  good  results. 

Cases  of  fracture  that  are  not  seen  until  some  time 
after  the  injury  are  often  very  difficult  to  reduce  at  once, 
owing  to  muscular  spasm  or  swelling  from  infection. 
Then  it  is  necessary  to  resort  to  slow  reduction  by  band- 
ages. Sometimes  a  mandibulomaxillary  splint  can  be 
inserted,  the  maxillary  portion  fitting  over  the  upper 
teeth,  and  the  lower  teeth  being  brought  up  into  position 
by  gradual  pressure  with  bandages.  Often  after  two 
or  three  days  of  the  application  of  this  double-inclined 
plane  principle  the  lower  teeth  will  be  found  to  have 
gained  their  normal  position  and  the  splint  can  be  firmly 
cemented  in  place. 

If  abscesses  form  on  the  face  or  neck,  they  must  be 
opened  and  drained.  If  sinuses  persist,  they  indicate 
necrosed  bone.  The  sinuses  must  be  kept  clean  by 
irrigation  with  a  germicidal  solution,  such  as  bichlorid  of 
mercury    i  :  2000.     Dioxid   of  hydrogen   must   not  be 


254  SPECIAL   SURGERY 

used  for  irrigation,  as  it  tends  to  spread  the  infection 
through  the  bone.  When  sequestra  become  loosened 
they  should  be  removed.  Teeth  loosened  at  the  seat 
of  fracture  should  usually  be  extracted  before  applying 
the  dressing,  as  they  eventually  will  be  lost,  and  are  a 
source  of  danger  of  infection  if  allowed  to  remain. 
When  only  slightly  loose  the  teeth  may  sometimes  be 
left  in  place. 

When  neuralgia  is  caused  by  pressure  of  callus  upon 
the  inferior  dental  nerve  or  its  branches,  it  may  become 
necessary  to  remove  the  redundant  bone,  or  even  to 
resect  a  portion  of  the  nerve-trunk.  Any  rough  spurs 
of  bone  can  easily  be  smoothed  away  with  the  surgical 
engine. 

In  treating  recent  cases  of  fracture  of  the  condyloid 
process  absolute  fixation  of  the  lower  to  the  upper  jaw 
by  means  of  interdental  splints  is  inadvisable,  owing  to 
the  proximity  of  the  fracture  to  the  joint,  with  consequent 
danger  of  ankylosis.  Ordinarily  all  that  is  necessary  is 
restriction  of  movement  by  means  of  a  modified  Barton 
bandage  not  too  tightly  applied,  with  instructions  to  the 
patient  to  use  the  jaw  with  moderation.  After  five  weeks, 
as  a  rule,  the  bandage  may  be  removed.  Where  there  is 
extreme  displacement  of  the  upper  fragment,  or  excessive 
deformity  from  deviation  of  the  chin,  or  where  ankylosis 
seems  unavoidable,  excision  of  the  condyle  followed  by 
arthroplasty  is  probably  advisable. 

In  the  treatment  of  fractures  of  the  upper  jaw  much 
depends  upon  the  position  and  extent  of  the  injury. 
In  most  cases  splints  are  not  required,  as  there  is  very 
little  displacement.  When  the  tuberosity  is  broken  off, 
as  in  extraction  of  a  third  molar,  an  attempt  should  be 


FRACTURES  2$$ 

made  to  obtain  union  by  bringing  the  upper  and  lower 
teeth  together  with  a  Barton  bandage.  If  the  parts  fail 
to  unite  after  a  reasonable  time,  the  fragment  should  be 
removed.  The  same  care  must  be  paid  in  regard  to 
cleanliness  and  extraction  of  loosened  and  diseased 
teeth  as  in  fracture  of  the  mandible.  Sometimes, 
after  gunshot  wounds,  or  perforation  of  the  hard  palate 
by  a  blunt  instrument,  a  permanent  opening  into  the 
nose  remains,  which  requires  closure  with  an  obturator. 

Review  Questions 

Give  the  four  principal  varieties  of  fracture  and  the  general  principles 
of  treatment. 

Give  the  etiology  and  commonest  seats  of  fracture  of  the  mandible. 

Give  reasons  for  its  common  occurrence  in  the  region  of  the  mental 
foramen. 

Give  the  complications  of  fracture  of  the  mandible. 

Give  the  sj'mptoms  and  diagnosis  of  fracture  of  the  mandible. 

Give  the  prophylactic  treatment  of  fracture  of  the  mandible.  Give 
the  simplest  form  of  treatment  in  which  the  occlusion  of  the  teeth  is 
good. 

What  is  the  best  splint  to  use  in  cases  where  there  are  several  good 
teeth  on  each  side  of  the  fracture? 

What  is  the  best  splint  when  the  teeth  are  poor  or  where  the  fracture 
is  behind  the  region  of  the  teeth? 

Describe  the  making  of  a  mandibulomaxillary  sjjlint  of  metal. 


CHAPTER  XXVII 
TRIFACIAL  NEURALGIA  AND  FACIAL  PARALYSIS 

Trifacial  Neuralgia 

The  word  neuralgia  signifies  a  pain  along  the  course 
of  a  nerve.  It  is  applied  to  any  pain  that  shoots  along 
the  course  of  a  nerve,  that  is  not  due  to  organic  disease 
of  the  nervous  system,  or  the  cause  of  which  is  not 
immediately  evident.  But  the  more  our  knowledge  ad- 
vances, the  more  is  trifacial  neuralgia  regarded  as  a 
symptom,  rather  than  a  disease  itself. 

Trifacial  or  trigeminal  neuralgia  may  be  broadly 
classified  into  two  forms:  (i)  In  which  no  cause  can  be 
found,  and  presenting,  a  definite  course  and  clinical 
picture — the  so-called  neuralgia  quinti  major,  or  tic 
douloureux;  (2)  in  which  the  pain  is  caused  by  some 
irritative  lesion  along  the  course  of  the  fifth  nerve — 
neuralgia  minor.  Some  authorities  make  other  sub- 
divisions of  the  disease,  for  example,  neuralgia  second- 
ary to  disease  of  the  nerves  of  the  head,  general  diseases, 
etc.  But  for  practical  purposes  the  classification  given, 
viz.,  neuralgia  in  which  a  cause  can  be  found  and  that 
in  which  no  cause  can  be  found,  is  sufficient.  With  the 
advance  of  our  methods  of  diagnosis,  such  as  by  the 
aj-rays,  and  a  better  knowledge  of  pathologic  lesions  of  the 
teeth  and  jaws,  the  latter  group  is  growing  smaller. 

Etiology. — Central  Lesions. — Tumors  of  the  brain  or 

256 


TRIFACIAL  NEURALGIA  257 

meninges,  or  of  the  roots  of  the  nerve  itself,  may  give 
rise  to  neuralgia.  Syphilitic  gummata  of  these  regions 
or  fracture  of  the  base  of  the  skull  may  cause  neuralgia 
by  pressure  on  the  roots  of  the  fifth  nerve.  These  causes 
nearly  always  produce  anesthesia  of  the  areas  supplied 
by  the  nerve,  especially  noted  in  the  intervals  between 
the  attacks  of  pain. 

Peripheral  Causes. — The  following  causes  may  result 
in  trifacial  neuralgia:  an  exposed  pulp  of  a  tooth,  peri- 
odontitis, an  impacted  tooth;  inflammatory  conditions 
of  the  jaw-bones  causing  increased  density  from  deposit 
of  lime  salts,  resulting  in  pressure  on  the  nerve  filaments; 
tumors  pressing  on  the  nerve- trunks;  pyorrhoea  alveo- 
laris;  eye-strain;  middle-ear  disease;  inflammation  of  the 
maxillary,  frontal,  and  sphenoid  sinuses  and  the  ethmoid 
air-cells. 

General  diseases  or  conditions  of  the  blood,  such  as 
anemia,  diabetes,  and  malaria,  may  result  in  trigeminal 
neuralgia.     No  cause  may  be  discoverable. 

Symptoms. — These  vary  greatly  in  intensity  according 
to  the  cause  and  extent  of  the  area  supplied  by  the  fifth 
nerve  that  is  involved.  In  some  cases  the  pain  is  con- 
fined to  one  or  two  divisions  of  the  nerve,  the  maxillary 
and  mandibular  divisions  being  most  frequently  involved. 
The  pain  is  not  always  confined  to  the  division  of  the 
nerve  supplying  the  seat  of  the  lesion,  but  may  be 
referred  to  other  parts  of  the  face.  In  the  so-called 
neuralgia  minor,  due  to  an  obvious  cause,  the  symptoms 
consist  usually  of  sharp,  shooting  pains  along  the  course 
of  the  nerve,  beginning  at  the  seat  of  the  lesion.  These 
pains  may  come  without  provocation,  and  as  suddenly 
disappear.     Cases  of  this  form  frequently  occur  in  which 

17 


,258  SPECIAL    SURGERY 

the  character  of  the  attacks  cannot  be  distinguished  from 
that  of  the  more  severe  form,  and  this  leads  one  to  sup- 
pose that  all  cases  of  trifacial  neuralgia  have  an  original 
cause  in  irritation  somewhere  along  the  course  of  the 
fifth  nerve.  This  is  further  borne  out  by  the  discovery 
and  removal  of  local  causes,  followed  by  cure,  in  cases 
previously  diagnosed  by  neurologists  as  neuralgia  major. 
It  is  obvious  that  when  a  cause  has  been  found,  the  con- 
dition of  the  patient  should  not  be  referred  to  as  neur- 
algia, but  classified  according  to  the  particular  lesion  of 
which  the  neuralgia  is  merely  a  symptom.  Thus  a 
case  of  brain  tumor  pressing  upon  the  roots  of  the 
fifth  nerve  would  not  be  called  neuralgia  after  diagnosis 
of  the  cause  was  made.  The  pain  of  neuralgia  is  accom- 
panied by  more  or  less  tenderness  of  certain  points, 
particularly  over  the  supra-orbital,  infra-orbital,  and 
mental  foramina,  the  peripheral  points  of  exit  of  the 
branches  of  the  nerve. 

In  the  severe  form  of  the  disease,  neuralgia  quinti 
major,  or  tic  douloureux,  the  case  begins  as  one  of  sim- 
ple neuralgia,  but  does  not  respond  to  treatment,  and 
search  for  a  cause  proves  fruitless.  The  attacks  of 
sharp  shooting  pain  increase  in  frequency  and  severity, 
and  often  interfere  with  any  kind  of  work  on  the  part 
of  the  patient.  They  often  come  on  without  any  obvious 
cause,  but  are  sometimes  apparently  induced  by  sudden 
shock,  exposure  to  cold,  or  even  talking.  The  attacks 
may  last  for  a  few  seconds  or  for  several  minutes,  and 
depart  as  suddenly  as  they  come.  During  the  par- 
oxysms the  patient  may  scream  and  roll  on  the  floor  in 
agony,  and  life  becomes  unbearable.  The  pain  is  ac- 
companied by  twitching  of  the  facial  muscles  (tic),  and 


TRIFACIAL   NEURALGIA  259 

thus  it  is  seen  that  the  seventh  nerve  is  involved  in  the 
disease  as  well  as  the  fifth.  The  skin  on  the  side  of 
the  face  affected  is  flushed,  and  trophic  changes,  such  as 
falling  out  of  the  hair,  sometimes  occur. 

Diagnosis. — It  is  of  the  highest  importance  that 
cases  due  to  a  local  irritation  of  the  fifth  nerve  be  dis- 
tinguished from  those  in  which  no  cause  can  be  found. 
The  character  of  the  attacks  of  pain  and  its  location 
will  often  lead  easily  to  the  source  of  the  trouble.  A 
careful  examination  of  the  mouth,  teeth,  accessory 
sinuses,  etc.,  should  be  made  in  all  cases.  The  x-ray 
is  the  most  valuable  means  of  diagnosis  of  obscure 
lesions  of  the  face  and  jaws  that  wt  possess,  and  no  case 
of  trigeminal  neuralgia  should  be  allowed  to  go  without 
careful  examination  of  a  good  :r-ray  picture  that  in- 
cludes the  entire  facial  region.  By  neglect  of  this  pre- 
caution many  hidden  causes  are  overlooked  and  the 
case  placed  in  the  class  of  neuralgia  major. 

Prognosis. — This  depends  upon  the  removal  of  the 
cause  and  the  duration  of  the  trouble.  If  the  cause  can 
be  located  and  removed  and  the  symptoms  have  not 
existed  for  too  long  a  period,  a  cure  can  be  expected. 
In  cases  of  long  standing,  however,  the  pains  may  con- 
tinue after  the  cause  has  been  removed.  When  the 
cause  cannot  be  determined,  resection  of  portions  of  the 
nerve  is  frequently  followed  by  recurrence,  and  even 
extirpation  of  the  Gasserian  ganglion  may  not  effect 
a  cure. 

Treatment. — This  consists  in  removing  the  cause,  if 
it  can  be  found.  Extraction  of  an  impacted  tooth, 
excision  of  a  tumor  pressing  on  the  fifth  nerve  or  its 
branches,   drainage   of   suppurating   accessory   sinuses. 


26o  SPECIAL   SURGERY 

in  short,  removal  of  any  irritation  to  the  nerve,  will  in 
most  cases  effect  a  cure.  When  the  neuralgia  is  due  to 
general  diseases,  such  as  malaria,  anemia,  etc.,  these  dis- 
eases are  to  be  treated,  and  the  neuralgia  will  disappear 
as  soon  as  they  are  cured.  The  systemic  treatment 
consists  in  building  up  the  health  of  the  patient  with 
nutritious  food,  tonics,  exercise,  etc. 

When  no  cause,  either  systemic  or  local,  can  be  dis- 
covered and  during  the  attacks  of  pain  palliative 
measures  must  be  used.  This  consists  in  the  local 
appHcation  of  hot  cloths,  blisters,  liniments,  etc.,  and 
the  administration  of  analgesics,  such  as  antipyrin  or 
phenacetin.  Cannabis  indica  often  affords  great  relief, 
and  may  be  given  as  follows : 

R.   Codein.  sulph gr.  viij; 

Ext.  cannabis  ind gr.  iv. — M. 

Ft.  capsul.  No.  xvi. 

SiG. — One  capsule  every  four  hours. 

It  is  not  wise  to  use  opium  except  as  a  last  resort, 
because  of  the  danger  of  habit  formation.  The  value 
of  palliative  treatment  lies  only  in  relief  of  the  patient 
until  an  operation  can  be  performed,  or  in  cases  in  which 
an  operation  is  contraindicated. 

In  cases  of  neuralgia  in  which  the  pain  is  confined  to 
one  division  of  the  fifth  nerve  the  operation  of  resection 
of  a  portion  of  the  nerve  may  be  tried.  The  object  is 
to  sever  the  nerve  at  a  point  between  the  point  of  irrita- 
tion and  the  nerve-centers.  These  peripheral  operations 
are  usually  performed  in  the  region  of  exit  of  the  nerve 
from  the  skull  on  to  the  face.  The  ophthalmic  division 
is  reached  at  the  supra-orbital  foramen,  where  the  supra- 
orbital nerve  emerges  on  the  face. 


TRIFACIAL   NEURALGIA  26 1 

Resection  of  the  Infra-orbital  Branch.— This  is  best 
performed  by  an  incision  in  the  vestibule  of  the  mouth,  as 
scarring  of  the  face  is  thereby  avoided.  General  anes- 
thesia is  required.  The  upper  lip  is  raised  and  held  up 
with  a  retractor.  The  tissue  of  the  chieek  is  divided  by 
an  incision  upward  from  the  top  of  the  vestibule  of  the 
mouth,  the  knife  keeping  close  to  the  bone  until  the  nerve 
is  found  as  it  emerges  from  the  infra-orbital  foramen. 
The  nerve  is  grasped  with  a  tenaculum  or  pair  of  hemo- 
static forceps  and  divided.  The  distal  portion  of  the 
nerve  is  first  pulled  upon,  and  as  much  of  it  removed  as 
possible  by  this  means  (avulsion) .  The  portion  emerging 
from  the  foramen  is  then  treated  in  the  same  way.  By 
this  means  it  is  sometimes  possible  to  remove  the  nerve 
as  far  back  as  Meckel's  ganglion.  If  the  infra-orbital 
artery  is  divided,  it  must  be  Ugated.  After  avulsion 
of  the  nerve  the  wound  is  lightly  packed  with  gauze. 
If  the  incision  has  been  large,  one  or  two  silk  sutures  may 
be  inserted,  but  the  wound  should  never  be  entirely 
closed,  as  there  is  always  some  infection.  This  rarely 
amounts  to  much,  however,  and  is  treated  by  keeping 
the  mouth  as  clean  as  possible,  the  use  of  mouth-washes, 
etc.;  the  gauze  drain  should  be  changed  twice  a  day,  a 
smaller  piece  being  inserted  each  time,  until  the  wound 
presents  no  pockets  that  could  hold  pus. 

Resection  of  the  Mental  Branch  at  the  Mental  Foramen. 
— This  is  done  through  an  incision  in  the  vestibule  of 
the  mouth  over  the  mental  foramen,  which  lies  below 
and  between  the  two  lower  premolar  teeth.  The  nerve 
is  grasped  as  it  emerges  from  the  foramen,  and  a  portion 
removed,  as  in  the  case  of  the  infra-orbital  branch. 
Sometimes  it  is  of  advantage  to  cut  away  a  portion  of 


262  SPECIAL    SURGERY 

bone  surrounding  the  nerve  before  it  emerges  with  the 
surgical  engine,  and  in  this  connection  it  must  be  re- 
membered that  the  nerve  at  this  position  is  recurrent, 
running  backward  to  the  foramen,  so  that  the  bur 
must  cut  in  a  direction  toward  the  symphysis'  menti. 

Resection  of  the  Inferior  Dental  Branch. — This  opera- 
tion is  usually  performed  near  the  point  of  entrance  of 
the  nerve  into  the  inferior  dental  tube.  The  skin 
behind  the  ramus  of  the  lower  jaw  is  drawn  forward, 
so  that  the  scar  left  by  the  operation  will  be  hidden 
behind  the  ramus.  A  vertical  incision,  parallel  to  the 
fibers  of  the  masseter  muscle,  about  three-quarters  of 
an  inch  in  length,  is  made  over  the  middle  of  the  ramus 
down  to  the  bone,  the  skin,  superficial  fascia,  deep  or 
masseteric  fascia,  masseter  muscle,  and  periosteum  being 
cut  through.  Peripheral  fibers  of  the  facial  nerve  run- 
ning to  the  muscles  of  expression  about  the  lower  lip 
are  also  unavoidably  divided  by  this  incision,  thus 
accounting  for  the  temporary  paralysis  of  the  muscles 
mentioned  following  this  operation,  the  paralysis  disap- 
pearing eventually  when  regeneration  of  the  nerve- 
fibers  takes  place.  After  the  incision  is  made,  the  peri- 
osteum is  lifted  away  from  the  bone.  A  hole  is  now 
trephined  with  the  surgical  engine  on  the  outer  side  of 
the  ramus  corresponding  to  the  position  of  the  inferior 
dental  foramen  on  its  inner  side.  This  point  is  situated 
in  the  center  of  the  ramus,  i.  e.,  between  its  anterior  and 
posterior  edges,  and  midway  between  the  bottom  of  the 
sigmoid  notch  and  the  angle  of  the  mandible.  The 
trephine  is  made  to  pass  through  the  whole  thickness  of 
the  ramus,  and  the  hole  may  then  be  prolonged  downward 
with  a  surgical  bur.     This  exposes  the  inferior  dental 


TRIFACIAL    NEURALGIA  263 

nerve  as  it  enters  the  mandibular  tube.  The  nerve  is 
grasped  with  a  pair  of  hemostatic  forceps  and  divided, 
about  half  an  inch  of  it  being  removed.  Sometimes  the 
entrance  to  the  bony  canal  is  packed  with  silver  foil  to 
prevent  reunion  of  the  cut  ends  of  the  nerve.  The 
button  of  bone  removed  b>'  the  trephine  may  now  be 
replaced  in  the  opening,  the  edges  of  the  masseter  muscle 
brought  together  with  buried  sutures  of  chromicized 
catgut,  and  the  skin  sutured  with  silk  or  silkworm-gut. 

In  making  the  primary  incision  one  must  avoid 
dividing  Stenson's  duct,  which  crosses  the  ramus  of  the 
mandible  about  half  an  inch  below  and  parallel  to  the 
zygoma.     Division  of  this  results  in  a  salivary  fistula. 

The  lingual  nerve  must  not  be  mistaken  for  the  inferior 
dental,  the  former  lying  in  front  of  and  above  the  latter. 

Care  must  be  taken  not  to  wound  the  inferior  dental 
artery  in  dividing  the  nerve,  as  serious  hemorrhage 
might  ensue. 

In  the  more  severe  cases  of  neuralgia  in  which  no 
cause  has  been  found  and  in  which  two  or  more  divisions 
of  the  fifth  nerve  are  involved,  removal  of  the  Gasserian 
ganglion,  or  division  of  the  sensory  root  of  the  nerve  as 
it  enters  the  gangUon,  gives  the  only  hope  of  cure. 
This  operation  is  one  of  the  most  dangerous  known  to 
surgery,  the  mortality  being  largely  due  to  hemorrhage. 
It  is  followed  by  complete  anesthesia  of  the  face  on  the 
side  operated  on.  Owing  to  loss  of  sensibility  of  the 
cornea,  ulceration  from  foreign  particles  is  liable  to  occur 
unless  the  eye  is  protected  by  a  watch-glass. 

Of  recent  years  brilliant  results  have  been  reported 
following  the  injection  of  akohol  in  trigeminal  neuralgia. 
By  means  of  a  special  syringe  the  alcohol  can  be  injected 


264  SPECIAL   SURGERY 

directly  into  the  nerve  as  it  emerges  through  the  foramen 
rotundum,  or  the  foramen  ovale,  or  into  the  Gasserian 
ganglion  itself.  It  is  possible  to  locate  these  foramina 
with  considerable  accuracy  by  means  of  certain  land- 
marks and  measurements.  With  this  method  rehef 
from  the  attacks  can  be  hoped  for  in  many  cases,  often 
lasting  for  several  years,  if  not  permanently. 

Facial  Paralysis 

This  is  a  loss  of  function  of  the  muscles  of  expression 
of  the  face  due  to  a  lesion  of  the  seventh  or  facial  nerve. 

Etiology. — Facial  paralysis  may  be  caused  by — (a) 
General  diseases;  (&)  lesions  of  the  cortical  facial  center 
or  of  the  seventh  nerve  nuclei  at  the  base  of  the  brain; 
(c)  lesions  of  the  nerve  within  the  aqueductus  Fallopii; 
((/)  lesions  of  the  nerve  after  its  exit  from  the  stylo- 
mastoid foramen. 

(a)  By  far  the  most  common  form  of  facial  paralysis 
is  the  so-called  ''  rheumatic  type,"  which  is  usually 
due  to  exposure  to  cold.  Other  general  diseases  with 
which  facial  paralysis  is  sometimes  associated  are 
alcoholic,  lead,  and  diphtheritic  neuritis,  malaria,  and 
uremia. 

(&)  Among  central  lesions  are  cerebral  hemorrhage 
(apoplexy),  embolism,  tumor,  or  gumma,  affecting  the 
cortical  area  for  the  face,  basal  meningitis,  gumma, 
or  tumor,  causing  pressure  upon  or  destruction  of  the 
nuclei  at  the  base  of  the  brain. 

(c)  Middle-ear  disease,  fracture  of  the  base  of  the  skull, 
tumors  involving  the  aqueductus  Fallopii. 

(J)  Peripheral  Causes. — Pressure  of  tumors  and 
inflammation  of  the  parotid  gland,  through  which  the 
nerve  and  its  branches  pass  after  leaving  the  skull. 


FACIAL    PARALYSIS  265 

Section  of  branches  of  the  nerve  by  injury  or  operation. 
Pressure  by  the  obstetric  forceps. 

Symptoms. — The  muscles  of  expression  on  the  side 
of  the  face  affected  are  paralyzed.  There  is  no  loss  of 
sensation.  The  side  of  the  face  affected,  including  the 
forehead,  is  smooth.  The  angle  of  the  mouth  droops, 
allowing   the   escape   of   saliva.     The   muscles   of    the 


Fig.  58. — Left-sided  facial  paralysis,  involving  all  three  groups  of  muscles 
supplied  by  the  seventh  cranial  nerve,  namely,  the  eye,  nasal  and  labial  groups. 
Note  the  obliteration  of  the  nasolabial  fold  on  the  side  of  paralysis,  the  drooping 
of  the  left  angle  of  the  mouth,  the  inability  to  close  the  left  eyelid,  and  loss  of 
action  of  the  muscles  of  the  eyebrows  (Eisendrath). 

unaffected  side  draw  the  mouth  toward  the  healthy  side 
(Fig.  58).  The  cornea  is  dry.  This  is  explained  by 
the  fact  that  the  facial  nerve  supplies  the  orbicularis 
palpebrarum,  and  when  this  is  paralyzed  there  is  no 
distribution  of  tears.  The  tears  tend  to  flow  over  on  to 
the  cheek,  instead  of  being  carried  to  the  lacrimonasal 
duct.    As  a  result  of  this  olfaction  is  interfered  with. 


266  SPECIAL   SURGERY 

Owing  to  partial  paralysis  of  the  buccinator  muscle, 
mastication  is  affected.  If  the  individual  laughs  or 
indulges  in  vigorous  speech,  the  cheek  is  puffed  out  with 
each  expiratory  effort.  Speech  is  affected,  owing  to 
lack  of  proper  movements  of  the  lips.  Sweating  on  the 
side  of  the  face  ceases  or  is  lessened,  as  a  rule.  The 
tongue  when  protruded  goes  to  the  affected  side,  being 
pushed  over  by  the  geniohyoglossus  muscle  of  the 
opposite  side. 

The  position  of  the  lesion  causes  variations  in  these 
symptoms.  When  it  is  central,  the  upper  part  of  the 
face  may  escape  paralysis  or  be  only  sHghtly  affected, 
because  this  part  receives  its  nerve-supply  from  both 
sides  of  the  brain.  Other  cranial  nerves  are  also  liable 
to  be  affected  by  central  lesions. 

BelVs  palsy  is  facial  paralysis  associated  with  loss  of 
sensation  of  taste  in  the  anterior  portion  of  the  tongue. 
It  is  caused  by  a  lesion  in  the  aquasductus  Fallopii  after 
the  chorda  tympani  joins  the  seventh  nerve  and  before 
it  leaves  it. 

In  lesions  of  the  nerve  behind  the  point  at  which  the 
nerve  to  the  stapedius  is  given  off,  sensitiveness  to  sounds 
may  be  increased  owing  to  paralysis  of  this  muscle. 
The  soft  palate  may  be  affected,  causing  interference 
with  swallowing  and  speech.  Deafness  is  often  associ- 
ated with  the  paralysis  when  the  cause  is  middle-ear 
disease. 

Prognosis. — This  depends,  first,  upon  the  seat  of  the 
lesion;  second,  upon  the  nature  of  the  lesion;  third, 
upon  the  damage  that  has  been  done  to  the  nerve,  as- 
certained by  electric  reactions. 

In  central  lesions  the  prognosis  for  recovery  is  unf avor- 


FACIAL    PARALYSIS  26/ 

able,  though  in  syphilitic  cases  marked  improvement  may 
sometimes  occur. 

Paralysis  secondary  to  middle-ear  disease  very  rarely 
shows  marked  improvement. 

In  the  peripheral  forms  and  those  due  to  general  dis- 
ease the  electric  reaction  is  a  good  guide  to  the  prognosis. 
It  is  not  favorable  if  reactions  of  degeneration  are  pres- 
ent. The  loss  of  excitability  to  the  faradic  current  may 
be  followed  by  recovery  in  about  three  months.  In 
traumatic  cases  the  prognosis  is  most  favorable. 

Treatment. — The  cause  should  be  determined  and,  if 
possible,  removed.  In  sj'philitic  lesions,  mercury,  po- 
tassium iodid,  or  salvarsan  (606)  may  be  beneficial.  Very 
little  can  be  done  in  other  central  lesions.  Middle-ear 
disease,  if  present,  should  be  treated.  Tumors  pressing 
upon  the  nerve  should  be  removed  if  possible.  In  the 
rheumatic  type,  when  slight,  a  small  bHster  behind  the 
ear  or  a  mustard  plaster  and  prevention  of  fresh  exposure 
to  cold  are  all  that  is  necessary.  Potassium  iodid  may 
be  of  some  benefit  in  lead  neuritis.  Massage  is  of  value 
in  all  cases  of  facial  paralysis.  Electricity  should  also 
be  used.  The  variety  selected  should  be  that  to  which 
the  muscles  respond.  In  cases  incurable  by  other  means, 
an  operation  uniting  the  distal  end  of  the  facial  nerve 
with  the  hypoglossal  has  been  attempted. 

Reviev  Questions 

Give  the  definition,  etiology,  symptoms,  diagnosis,  prognosis,  and 
treatment  of  trifacial  neuralgia. 

Give  the  operative  treatment  of  trifacial  neuralgia. 

Give  the  systemic  treatment  of  trifacial  neuralgia. 

Define,  and  give  the  etiology,  symptoms,  prognosis,  and  treatment  of 
facial  paralysis. 


NDEX 


Abducens  nene,  74 
Abscess,  102 

alveolar,  acute,  treatment  of,  191 
and  necrosis,  191 
dioxid  of  hj-drogen  in,  192 
opening  externally,  192 

into  maxillary  sinus,  192 
treatment  of,  191 
Actinomyces,  108 
Actinomycosis,  197 
etiology,  197 
metastases  in,  197 
prognosis,  198 
sj'mptoms,  197 
treatment,  198 
Adenofibroma,  163 
Adenoids,  213 

mouth-breathing  and,  213 
Adenoma,  163,  166 
Adhesive  plaster,  157 
Adrenalin  chlorid,  131 
and  novocain,  131 
Air  hunger,  1 24 
Alcohol,  injection  of,  for  neuralgia, 

263 
Alveolar  abscess.    See  Abscess,  al- 
veolar. 
process,  development  of,  22 
maxilla,  21 
Anastomosis,  71 
Anemia,  97 
and  trifacial  neuralgia,  257 


Anemia  in  svphilis,  1 75 
primarA',  98 
secondary,  98 
Anesthesia,  beta-eucain  hydrochlor- 
id,  130 
cocain  hydrochlorid,  130 
ether,  133,  140 
ethyl  chlorid,  130,  143 
general,  132 

intratracheal  insufflation,  141 
local,  130 

dangers  of,  131,  132 
for    extraction    of    teeth    and 
operations  about  jaw  bones, 

131 
superficial,  130 
tcchnic,  131 
nitrous  oxid,  141 

and  oxygen,  141 
novocain,  130 

and  adrenalin  chlorid,  131 
spinal,  130 
stovain  in,  130 
Anesthetic,  choice  of,  132 

general,  132 
Aneurysm  needle,  145 
Angina,  Ludwig's,  208 

Vincent's,  188 
Angiofibroma,  163,  169 
Angioma,  163,  166 
Angle  of  mandible,  changes  in,  26 
Ankylosis,  acute,  104 

269 


2/0 


INDEX 


Ankylosis,    acute,    and    impacted 

tooth,   2  21 

false,  220 
symptoms,  221 
treatment,  223 
and  change  in  shape  of  mandible, 

218 
and  tetanus,  223 
false,  218 
chronic,  219 
symptoms,  221 
treatment,  222 
of  temporomandibular  joint,  217 
and     swelling     of     parotid 
gland,  205 
true,  217 
etiology,  218 
symptoms,  221 
treatment,  220 
.v-ray  and,  221 
Anorexia,  104 
Anthrax,  107 
Antitoxin  in  septicemia,  118 

in  tetanus,  112 
Antrum  of  Highmore,  21,  39.    See 
Maxillary  sinus. 
diseases  of,  200 
Aorta,  63,  70 
Aphthous  stomatitis,  183 
Aqueductus  Fallopii,  84,  86 
Artery,  alveolar,  68 

ascending  pharyngeal,  50,  67,  93 

wound  of,  212 
basilar,  68 

common  carotid,  49,  50,  63 
branches,  63 
ligation  of,  145 
relations  of,  63 
surgical  line  of,  63 
external  carotid,  50 
branches,  68 
course,  67 


Artery,  external   carotid,   ligation 
of,  146 
facial,  50 

branches  of,  68 
course  of,  67 
inferior  dental,  68,  263 

thyroid,  49 
internal  carotid,  50 
branches  of,  66 
cavernous  portion,  65 
cervical  portion,  64 
course,  63 

intracranial  portion,  66 
petrous  portion,  65 
wound  of,  93,  212 
mammary,  51 
maxillary,  branches  of,  68 
course  of,  67 
divisions  of,  68 
hngual,  50,  67 

branches  of,  68 
occipital,  50,  67,  71 
ophthalmic,  33,  66 
posterior  auricular,  50,  67 
princeps  cervicis,  71 
profunda  cervicis,  71 
ranine,  68 
subclavian,  50,  71 
superficial  temporal,  67 
superior  intercostal,  51,  71 

thyroid,  50,  67 
thyroid  axis,  50 
transversalis  colli,  50 
vertebral,  49,  50,  63 
course  of,  68 
Auditory  meatus,  internal,  32 

nerve,  74 
Avulsion,  261 
Azygos  uvulae,  55 

Bacillus  aerogenes  capsulatus,  108 
anthracis,  107 


INDEX 


271 


Bacillus  coli  communis,  107 

diphtheriae,  108 

mallei,  107 

pj-ocyaneus,  107 

tuberculosis,  107 

typhosus,  107 
Bacteria  in  surgical  affections,  106 

pyogenic,  106 
Bandage,  Barton,  125,  158 

gauze,  157 

muslin,  157 
Bartholin,  duct  of,  91 
Barton  bandage,  125,  158 

in  fracture  of  mandible,  249 
modification,  15S 
Base  of  skull,  inferior  surface,  29 

internal  surface,  29 
Basilar  process,  32 

of  occipital  bone,  29 
Bell's  palsy,  266 
Benign  tumors,  164 
Beta-eucain  hydrochloric!,  130 
Bistoury,  149 
Blood  in  anemia,  98 

red  corpuscles,  97 

granular     degeneration     of, 

98 
nucleated,  98 

supply  of  head,  ^13 

of  teeth,  68,  70 

transfusion  in  hemorrhage,  12S 

white  corjjuscles,  98 
Blunt  dissector,  150 
Fionc,  ethmoid,  19 

frontal,  28 

hyoid,  26 

inferior  turbinated,  36 

intermaxillary,  34,  233 

lacrimal,  36 

malar,  28 

mandible,  22 

maxilla,  20,  28 


Bone,  middle  turbinated,  37 

palate,  36 

premaxilla,  233 

repair  of,  114 

sphenoid,  18 

sui:)erior  turbinated,  38 
Bones,  nasal,  34,  36 

of  face,  development  of,  17 

of  skull,  18 
Brachial  plexus,  51 
Branchial  folds,  25 
Brophy's  operation  for  cleft-palate, 

235 
Bulla  ethmoidalis,  38,  42 
Burs.  152 

Calculus  and  ranula,  207 
Camphorated  oil,  122 
Canal,  accessory  palatine,  34 

anterior  dental,  40 

carotid,  32 

inferior  dental,  24 

infra-orbital,  33 

lacrimonasal,  33 

of  Huguier,  85 

posterior  palatine,  34 
Cancellated  tissue  of  mandible,  24 
Cancer.     See  Carcinoma. 
Cancrum  oris,  186 
Cannabis  indica,  260 
Carcinoma,  163,  166 

diagnosis  from  sarcoma,  164 

encejjhaloid,  164 

hard,  164 

medullary,  164 

of  cheek,  166 

of  lip,  166 

of     mouth     and      submaxillary 
lymph-glands,  214 

of  [)ar()ti(l  gland,   205 

of  tongue,   166 
diagnosis  from  gumma,  177 


272 


INDEX 


Carcinoma,  scirrhous,  164 

soft,  164 

treatment  of,  166 
Cardiac  massage,  140 
Caries  of  bone,  106 
Carotid  canal,  32 

foramen.  29 

sheath,  48,  63 
Cartilage,  thyroid,  63 

triangular,  36 
Catgut,  155 

chromicized,  155 
Cautery,  actual,  170 
Cavernous  sinus,  65 
Cavity,  oral,  94 
Cellulitis,  104,  208 

and  streptococci,  io6 
Cervical  fascia,  47 
deep,  47 
superficial,  47 

glands,  deep,  72 
superficial,  72 

lymphatics,  72 

plexus,  50 
Chancre,  174 

of  lip,  diagnosis  from  epithelioma, 
176 
Cheek,  carcinoma  of,  166 
Childbirth,  injuries  during,  239 
Chill,  104 

in  pyemia,  118 
Chloroform,  132 

action  of,  132 

anesthesia,  mortality  from,  132 
Chondroma,  163,  166 
Circle  of  Willis,  69,  71 
Circulation,  collateral,  71 
Cleft  palate,  acquired,  231 
causes  of,  231 
treatment  of,  231 
vela  in,  231 
age  for  operation,  235 


Cleft    palate,   Brophy's   operation 
for,  23  s 
combined  with  harelip,  239 
complete,  234 
congenital,  233 

causes  of,  234 
double,  234 
incomplete,  234 
Lane's  operation,  237 
obturator  in,  231 
operator  treatment,  235 
single,  233 
syphilis  and,  231 
syphilitic,  177,  179 
taking  impression  in,  232 
Clinoid  process,  anterior,  29 
middle,  32 
posterior,  32 
Cocain  and  osteomyelitis,  194 

hydrochlorid,  130 
Cohnheim's  theory,  162 
Collapse,  120 

in  ether  anesthesia,  135 
pathology  of,  1 20 
symptoms  of,  121 
treatment  of,  122 
Collateral  circulation,  71 
Colon  bacillus,  107 
Condyle  of  mandible,  43 
Condyloid  process  of  mandible,  23, 
29 
fracture  of,  248 
treatment,  254 
of  occipital  bone,  29 
Congestion,  97 

Conjunctiva,  nerve  supply,  77 
Contusion,  definition,  109 
pathology,  109 
symptoms,  109 
treatment,  no 
Cornea,  ulceration  of,  263 
Corneal  reflex,  138 


INDEX 


273 


Coronoid  process  of  mandible,  22, 
29 
suture,  29 
Cranial  nerves,  74 
Cranium,  bones  of,  18 
Cravat  fascia,  47 
Cribriform  plate,  2q,  34 
of  ethmoid,  19 
tube  of  mandible,  24 
recurrent  portion,  25 
Crista  galli,  20,  29 
Cyanosis  in  ether  anesthesia,  139 
in  nitrous  oxid  anesthesia,  143 
Cyst,  164 

dentigerous,  172 
follicular,  171 
root,  171 
sebaceous,  166 

Deglutition,  54 

Dental  arch,  process  of  widening,  34 
Dentigerous  cyst,  172 
Development  of  mandible,  25 
Diabetes   and    trifacial    neuralgia, 

257 
Digastric  fossa  of  mandible,  23 
Dioxid  of  hydrogen  and  necrosis, 
196 
and  osteomyelitis,  192 
Diphtheria,  212 

antitoxin  in  hemorrhage,  125 
bacillus,  107 
Dislocation  of  temporomandibular 
joint,  displacement,  215 
etiology,  215 
symptoms,  216 
treatment,  217 
Double  lip,  160 
Drainage,  in,  112 

materials,  156 
Dressing  forceps,  150 
Dressings,  157 
18 


Drills,  152 

Drop-method  in  anesthesia,  137 

Duct  of  Bartholin,  91 

of  Rivinus,  91 

of  Stenson,  89,  263 
obstruction  of,  206 

of  Wharton,  90 

EccHYMOSis,  109 

Edema,  103 

Elevator,  152 

Eminentia  articularis,  27,  45 

Empyema  of  maxillary  sinus,  200 

Engine,  Cryer's  surgical,  154 

Enteroclysis,  121 

Epiglottis,  95 

Epistaxis,  123 

Epithelioma,  163,  165,  166 

diagnosis  from  chancre  of  lip,  1 76 
of  face,  166 
Epulis,  168 
fibrous,  169 
treatment  of,  1 70 
Erysipelas,  106 
Erythrocytes,  97 
Ether,  132,  140 
action  of,  135 
anesthesia,  133 

cardiac  failure  in,  140 

massage  in,  140 
circulatory  failure  in,  139 
color  in,  139 
cyanosis  in,  139 ' 
drop-method,  137 
fourth  stage,  134 
method  of  administration,  137 
minor  operations  under,  135 
mortality  from,  132 
musculospiral  paralysis  in,  138 
oxygen  in,  140 
position  of  patient,  136 
precautions,  135 


274 


INDEX 


Ether  anesthesia,  preparation  for, 
135, 136 

primary  stage,  133,  134 

pupil  in,  139 

respiration  in,  138 

respiratory  failure  in,  139 

second  stage,  134 

stage  of  excitement,  134 
of  relaxation,  134 

stages  of,  133 

stimulants  in,  139 

third  stage,  134 

vomiting  in,  139 

wire  mask  for,  137 

with  nitrous  oxid,  136 
cause  of  death  by,  135 
comparison      with     chloroform, 

132 
contraindications  to,  133 
effect  on  kidneys,  136 
inflammability  of,  140 
narcosis,  133 
vapor  and  air,  140 
Ethmoid  bone,  ig 

cribriform  plate,  19 

crista  galli,  20 

laterla  masses,  20 

OS  planum,  20 

perpendicular  plate,  19 

vertical  plate,  19 
cells,  anterior,  37,  43 

middle,  20,  37,  43 

outlets,  43 

posterior,  38,  43 
cribriform  plate,  34 
turbinated  processes,  36 
unciform  process,  38 
vertical  plate,  36 
Ethyl  chlorid,  130,  132,  143 
Eustachian  tube,  54,  55 
External  auditory  meatus,  28 
Extravasation,  109,  123 


Face,  bones  of,  18 
epithelioma  of,  166 
lymphatics  of,  72 
motor  nerve,  supply  of,  83 
nerve  supply  of,  75 
tumors  of,  166 
wounds  of,  15s 
Facial  nerve,  74,  83 
notch,  23 
paralysis,  264 

and  swelling  of  parotid  gland, 

205 
central  lesions  and,  264 
electrical  reaction  and,  267 
etiology,  264 
general  diseases  and,  264 
middle-ear  disease  and,  264 
parotid  gland  and,  264 
peripheral,  causes,  264 
prognosis,  266 
rheumatic  type,  264 
symptoms,  265 
treatment,  267 
Fascia,  cervical,  47 
parotid,  48 
prevertebral,  48 
Fauces,  pillars  of,  54,  92,  95 
Fever  in  inflammation,  103 

surgical,  115 
Fibrin  ferment,  115 
Fibroblasts,  113 
Fibroma,  163,  166 
Fibromyoma,  163 
Fibrous  epulis,  169 
Fissure,  Glaserian,  45,  85 
sphenoid,  32,  33,  76 
sphenomaxillary,  2,2>-,  77,  7^ 
Fistula,  102 

salivary,  207,  263 
Floor  of  mouth,  59,  95 

of  nose,  36 
Fluctuation,  103 


INDEX 


275 


Foramen,  accessory  palatine,  29 
anterior  condyloid,  29,  32 

ethmoid,  32,  zi 

lacerated,  32 

palatine,  29 
carotid,  29 
for  nasal  ner\-e,  32 
inferior  dental  (mandibular),  23, 

-M,  79 
infra-orbital,  28,  77 
jugular,  29,  32 
magnum,  29,  32 
malar,  33 

mental,  23,  25,  28,  79 
middle  lacerated,  29,  32 
of  Scarpa,  21,  34 
of  Stenson,  21,  34 
olfactory,  t^i 
optic,  32,  33 
ovale,  29,  32,  76,  78 
posterior  condyloid,  29,  32 

ethmoid,  32,  i^, 

lacerated,  29,  32 

palatine,  29 
rotundum,  32,  77 
spinosum,  29,  32 
stylomastoid,  29,  84 
supra-orbital,  28 
Forceps,  AUis',  150 
dental,  152 
dressing,  150 
hemostatic,  150 
Fossa,  anterior  palatine,  34 
glenoid,  29,  42 
nasal,  28,  34 
of  skull,  anterior,  29 

middle,  29,  32 

posterior,  29,  32 
pterygoid,  29 
scaphoid,  54 

sphenomaxillary,  41,  77,  78,  81 
Fracture,  242 


Fracture,  classification,  242 
comminuted,  242 
compound,  242 
general  principles  of  treatment, 

242 
greenstick,  242 

of  condyloid  process  of  mandible, 
244,  248 
treatment  of,  254 
of  mandible,  243 

abscess  and,  245 

and  anesthesia  of  lip,  245 

afangle,  244 

at  mental  foramen,  244 

Barton  bandage  in,  249 

bilateral,  244 

bone  plates  in,  251 

cellulitis  and,  245 

complications  of,  244 

delayed  union,  245 

disinfection  of  mouth  in,  248 

during  delivery,  244 

etiology,  243 

feeding  patient  in,  249 

following  necrosis,  246 

Gilmer's  treatment,  250 

impressions     and     casts     for 
splint,  251 

in  edentulous  mouth,  253 

infection,  245 

involvement  of  teeth,  245 

Ludvvig's  angina  and,  246 

mandibulomaxillary     metal 
splint,  252 

metal  bands  in,  251 
splint,  252 

necrosis  and,  245 

neuralgia  and,  245,  254 

non-union,  245 

plaster-of-Paris     bandage    in, 
250 

seat  of  fracture,  243 


2/6 


INDEX 


Fracture  of  mandible,  slow  reduc- 
tion of,  253 

splints  in,  250 

symptoms  and  diagnosis,  246 

treatment  of,  248 
of  infection,  253 
of  loose  teeth,  254 

vulcanite  interdental  splint  in, 

251 
a;-ray  in  diagnosis,  248 
of  upper  Jaw,  243 

treatment,  254 
simple,  242 
Frontal  bone,  28 
nasal  spine,  36 
orbital  plate,  29 
process,  42 
sinus,  37,  42 
infection  of,  201 
variations,  43 

Ganglion,  ciliary,  80 
Gasserian,  76,  77,  263 
geniculate,  86 
lenticular,  80 
Meckel's.  54,  81 

branches  of,  81 
ophthalmic,  77,  80 

branches,  80 
otic,  55,  82 

branches,  82 
sphenopalatine,  81 
submaxillary,  82 
Gangrene,  dry,  105 
emphysematous,  108 
moist,  105 
Gasserian  ganglion,  76,  77 
depression  for,  32 
removal  of,  263 
Gauze  dressing,  157 
for  drainage,  156 
Genial  tubercles,  23 


Geniculate  ganglion,  86 
Giant-cell  myeloma,  166,  169 
Gilmer's  treatment  of  fracture  of 

mandible,  250 
Gland,  parotid,  67,  84,  88 
accessory,  89 
anatomic  relations,  89 
blood  supply,  89 
diseases  of,  205 
duct  of,  89 
function,  88 
lymphatics  of,  90 
nerve  supply,  89 
secretion,  88 
situation,  89 
structures  found  in,  90 
tumors  of,  170 
sublingual,  91 
anatomic  relations,  91 
ducts  of,  91 
nerve  supply,  82 
secretion,  91 
submaxillary,  50,  90 
anatomic  relations,  90 
blood  supply,  90 
coverings  of,  90 
duct  of,  90 
nerve  supply,  82,  90 
secretion,  90 
Glanders,  107 
Glands,  buccal,  91 
labial,  91 
lingual,  91 
mucous,  91 
palatal,  91 
salivary,  88 
diseases  of,  205 
Glaserian  fissure,  45,  85 
Glenoid  fossa,  29,  42 
Glossopharyngeal  nerve,  74 
Gonococcus,  107 
Granulation  tissue,  114 


INDEX 


277 


Grooved  director,  150 
Growth,  new,  162 

of  mandible,  25 
Gumma,  176,  179 

of  hard  palate,  177 

of  tongue,  177 

diagnosis,  from  carcinoma,  177 
Gums,  hypertrophy  of,  1 59 

Hamular  process,  19,  33,  55 
Hard  palate,  21,  29 
gumma  of,  177 
Harelip,  237 

combined  with  cleft  palate,  239 

treatment  of,  237 
Head,  blood  supply,  63 

veins  of,  69 
Healing  by  first  intention,  114 

by  primarj'  union,  114 

by  second  intention,  114 

by  third  intention,  114 
Hematemesis,  123 
Hematoma,  109,  123 
Hematuria,  123 
Hemoglobin,  97 

normal  percentage,  97 
Hemophilia,  126 

blood  in,  126 

etiology,  126 

pathologj',  126 

prognosis,  127 

symptoms,  127 

treatment,  127 
Hemoptysis,  123 
Hemorrhage,  122 

anatomic  varieties,  123 

arrest  of,  iii,  124 

arterial,  123 

blood  transfusion  in,  128 

capillary,  123 
persistent,  125 

clinical  classification,  123 


Hemorrhage,  constitutional  effects 
of,  124 
treatment  following,  126 

following  tooth  extraction,  125 

from  particular  regions,  1 23 

intermediate,  123 

internal,  123 

primary,  123 

secondary',  123 

serum  treatment,  125,  128 

spontaneous  arrest  of,  1 24 

treatment  of,  124 

venous,  123,  124 
Hemorrhagic  diathesis,  126 
Hemostatic  forceps,  150 
Hiatus  semilunaris,  38,  41 
Highmore,  antrum  of,  39.    See  also 

Maxillary  sinus. 
Horsehair,  155 
Huguier,  canal  of,  85 
Hutchinson's  teeth,  178 
Hyoid  bone,  26 

muscular  attachments,  27 
Hyperemia,  active,  97 

passive,  97 
Hyperplasia,  159 
Hypertroph\-,  159 

acquired,  159 

inherited,  159 

of  gums,  159 
Hypodermoclysis,  121 
Hypoglossal  ner\'e,  75 

Impacted  teeth,  224 

acute  exanthemata  and,  226 
and  trifacial  neuralgia,  257 
canine,  225 
diagnosis  of,  228 
etiology,  226 
general  effects,  229 
heredity  and,  228 
in  maxillary  sinus,  203 


278 


INDEX 


Impacted  teeth,  local  effects,  228 

order  of  impaction,  224 

symptoms,  228 

third  molar,  225 

treatment  of,  229 

a;-rays  and,  228 
Incisor  teeth,  germs  of,  34 
Inflammation,  acute,  99 
bacteria  and,  99 
causes,  99 
chronic,  99 
definition  of,  99 
diapedesis,  100,  loi 
edema  in,  103 
emigration    of   leukocytes,    100, 

lOI 

etiology,  99 

fever  in,  103 

gangrenous,  104 

leukocytosis  in,  104 

margination  of  leukocytes,  100 

pathology  of,  100 

phagocytosis,  loi 

phlegmonous,  104 

resolution,  loi 

stasis,  100 

suppuration,  loi,  102 

symptoms  of,  102 

terminations  of,  loi 

tissue  changes  in,  100 

treatment  of,  104 
Inframaxillary    branch    of    facial 

nerve,  86 
Infra-orbital  canal,  20,  33 

foramen,  28 

nerve,  33,  77 

vessels,  i'^ 
Infundibulum,  38 
Instruments,  149 

for  operation  within  the  mouth, 
152 
Interarticular  fibrocartilage,  46 


Interarticular  fibrocartilage,  muscle 

to,  57 

Intermaxillary  bone,  34,  233 
suture,  opening  of,  34 

Intratracheal  insufiflation  anesthe- 
sia, 141 

Intravenous    injection    of    normal 
saline,  139 

Involucrum,  194 

lodin  in  sterilization,  iii,  148 

Iritis  in  syphilis,  175 


Jaw  bones,  osteomyelitis  of,  192 
operations  about,  local  anesthesia 

for,  131 
sarcoma  of,  168 
tumors  of,  166 

Joint,  temporomandibular,  45 

Jugular  foramen,  29,  32 

Knives,  149 
Knot,  square,  156 
surgeon's,  156 

Labor  and  deformity  of  Jaws,  241 
Lacrimal  bone,  36 
Lacrimonasal  canal,  33 

duct,  36 
Lambdoid  suture,  29 
Lane's  operation  for  cleft  palate, 

237 
Lateral  wall  of  nose,  36 
Lead  poisoning,  190 
Leukemia,  98 
Leukocytes,  98 

emigration  of,  100,  loi 

margination  of,  100 

polymorphonuclear,  98 
Leukocytosis,  98,  104 
Leukoplakia,  172 


INDEX 


279 


Leukoplakia,  diagnosis  from  mu- 
cous patches,  177 

etiology,  172 

prognosis,  173 

sjTnptoms,  172 

s\philis  and,  172 

treatment,  172 
Ligament,  capsular,  46 

external  lateral,  46 

internal  lateral,  46 

sphenomandibular,  46 

stylomandibular,  46,  88 
Ligation  of  common  carotid  artery, 

145 
of  external  carotid  artery,  146 
Ligature,  155 
catgut,  155 
silk,  155 
Lingualis  muscle,  53 
Lip,  carcinoma  of,  166 
Lipoma,  163,  166 
Lock-jaw,  107,  223 
Ludvvig's  angina,  208 

and  fracture  of  mandible,  246 
etiology  and  pathology,  208 
prognosis,  209 
symptoms,  208 
treatment,  209 
Lues,  174 

Lymph-glands,  affections  of ,  213 
parotid,  72 
submaxillary,  72 
L>'mphangioma,  163 
Lymphatics,     cervical     carcinoma 
and, 166 
epitrochlear,  175 
in  syphilis,  175 
of  face,  72 
of  neck,  72 
postcervical,  175 
submaxillary,  in  syphilis,  176 
Lymphoma,  163 


Macular  eruption  in  syphiHs,  175 
Magnum,  foramen,  32 
Malar  bone,  28 

foramina,  33 
Malaria  and  trifacial  neuralgia,  257 
Malignant  pustule,  107 

tumors,  164 
Malleus,  processus  gracilis,  45 
Mandible,  22 

alveolar  process,  23 

angle,  26 

body,  22 

cancellated  tissue,  24 

changes  in  shape  following  an- 
kylosis, 218 

condyle,  43 

condyloid  process,  23,  29 
fractures  of,  248 
treatment,  254 

coronoid  process,  22,  29 

cribriform  tube,  24,  79 

development  and  growth  of,  25 

digastric  fossa,  23 

external  oblique  line,  23 

facial  notch,  23 

fracture  of,  243 

Gilmer's  treatment,  250 

genial  tubercles,  23 

inferior  dental  (mandibular)  fora- 
men, 23,  24 

internal  structure,  24 

lingula,  23 

mental  foramen,  23,  25 
process,  23 

muscles  attached  to,  61 

mylohyoid  groove,  23 
ridge,  23 

ramus,  22 

sigmoid  notch,  23 

sublingual  fossa,  23 

submaxillary  fossa,  23 

symphysis,  23 


28o 


INDEX 


Mandible,  transverse  section,  24 
Massage  and  facial  paralysis,  267 
Masseter  muscle,  55 
Mastication,  accessory  muscles  of, 

55 
muscles  of,  55 
Mastoid  process,  28,  29 
Maxilla,  20,  28 

alveolar  process,  21 
anterior  palatine  fossa,  21 
cavities  formed  by,  22 
development  of,  233 
facial  surface,  21 
foramen  of  Scarpa,  21 

of  Stenson,  21 
fractures  of,  243 
lateral  processes,  34 
malar  process,  21 
nasal  process,  36 

surface,  20 
orbital  surface,  20 
palatal  process,  20,  33 
treatment  of  fracture  of,  254 
tuberosity,  21 
zygomatic  surface,  21 
Maxillary  sinus,  21,  37,  38 

acute  empyema  of,  201 

anterior  wall,  40 

catarrhal  inflammation  of,  200 

chronic  suppuration,  201 

communication    with    frontal 
sinus,  42 

diseases  of,  200 

drainage  of,  202 

empyema  of,  200 

floor,  40 

impacted  teeth  in,  203 

na,sal  wall,  41 

outlet,  41 

pathologic  outlet,  42 

polypi  of,  203 

posterior  wall,  41 


Maxillary  sinus,  proximal  wall,  41 
roof,  39 

selection  of  opening,  212 
septa,  40 
shape,  39 
suppurative  inflammation  of, 

200 
transillumination  and,  201 
treatment  of  empyema  of,  202 
tumors  of,  203 
variations  in,  39 
x-ray  and,  201 
Meati  of  nose,  number  of,  36 
Meatus,  fifth,  38 
fourth,  38 
inferior,  36 

opening  into,  37 
internal  auditory,  32 
middle,  37,  41 

cells  communicating  with,  37 
superior,  38 

cells  communicating  with,  38 
supreme,  38 
Meckel's  cartilage,  25 

ganglion,  54,  81 
Mental  foramen,  23,  25,  28 

and  fracture  of  mandible,  244 
Mercurial  stomatitis,  188 
Mercury  in  syphilis,  181 
Metastasis  of  tumors,  164 
Mouth,  94 

breathing  and  adenoids,  213 

and  hypertrophy  of  tonsils,  211 
disinfection  in  fracture  of  man- 
dible, 248 
floor  of,  59,  95 
glands  of,  88 
inlet  of,  95 
manifestations  of  lead-poisoning 

in,  190 
outlet  of,  95 
preparation  for  operation,  148 


INDEX 


281 


Mouth,  roof  of,  n,  94 
syphilitic  lesions  of,  176 
treatment  of,  in  s>T)hihs,  181 
vestibule  of,  95 
wounds  of,  113 
Mouth-gag,  152 
Mouth-mirror,  152 
Mucous  membranes,  wounds  of,  113 
cleansing  of,  113 
closure  of,  113 
drainage  of,  113 
hemorrhage  of,  113 
infection  of,  113 
made  by  surgeon,  113 
suture  of,  113 
tincture  of  iodin  in,  113 
treatment,  113 
patches,  175 

diagnosis  from  leukoplakia,  177 
from  simple  ulcers,  177 
Mumps,  205 

Muscle    or    muscles    attached    to 
mandible,  61 
azygos  uvulae,  55 
buccinator,  58,  61,  83 
depressor  anguli  oris,  60,  61 
labii  inferioris,  60,  61 
superioris,  59 
digastric,  49,  50,  58,  61,  83 
external  pterygoid,  57,  61 
geniohyoglossus,  51,  61 
geniohyoid,  59,  61 
hyoglossus,  51 
inferior  constriction  of  pharynx, 

SI 
internal  pterygoid,  56,  61 
levator  anguli  oris,  60 
labii  inferioris,  61 
superioris,  59 
ala;que  nasi,  59 
menti,  61 
lingualis,  53 


Muscle,  masseter,  55,  61 

middle  constriction  of  pharynx, 

53 

mylohj-oid,  58,  60,  61,  95 

of  expression,  59 
nerve  supply  of,  83 

of  mastication,  55 
accessory,  55 
nerve  supply,  79 

of  pharynx,  53 

of  soft  palate,  53 

of  tongue,  51 

omohyoid,  49,  50 

orbicularis  oris,  59,  95 

palatoglossus,  51,  54,  92 

platysma  mj^oides,  58,  61,  83 

quadratus  menti.  60 

risorius,  60 

sternocleidomastoid,  48 

sternomastoid,  49,  50 

stjdoglossus,  53 

stylohyoid,  83 

stylopharj-ngeus,  54 

superior  constrictor  of  pharynx, 
53,  61 

temporal,  55,  61 

tensor  palati,  54 

trapezius,  50 

triangularis  menti,  60 

zygomaticus  major,  60 
minor,  59 
Myeloma,  163,  169 
Myelosarcoma,  163 
Myxoma,  163 

Xares,  anterior,  39 

posterior,  29,  39 
Nasal  bones,  35 

chamber,  lateral  wall,  36 

fossa,  28,  34 

meati,  36 

nerve,  33 


282 


INDEX 


Nasal  process  of  maxilla,  36 
septum,  36 
spine,  36 
Nasopalatine  nerve,  34 
Neck,  lymphatics  of,  72 
surgical  square  of,  48 
triangles  of,  48 
Necrosis,  105,  194 

and  dioxid  of  hydrogen,  196 

causes,  194 

followed  by  fracture  of  mandible, 

246 
involucrum,  194 
phosphorus,  195 
sequestrum,  194 
syphilitic,  177,  179,  195 
treatment,  195 
tuberculous,  195 
a:-ray  and,  195 
Needle-holder,  156 
Needles,  156 
Neoplasm,  162 

hyperplasia  in,  159 
Nerv^e,  abducens,  74 
anterior  palatine,  81 
auditory,  74,  84 
auriculotemporal,  67,  79 
chorda  tympani,  85 
cranial,  action  of  anesthetics  on, 
132 
table  of,  74 
descendens  hypoglossi,  50,  63 
digastric,  85 
external  laryngeal,  54 

palatine,  81 
facial,  54,  60,  61,  74,  83 
branches,  84 
course  of,  84 
deep,  origin,  83 
paralysis  of,  264 
superficial,  origin,  83 
temporofacial  division,  85 


Nerve,  fifth,  t,^,  75 
fourth,  33 
frontal,  76 

glossopharyngeal,  50,  54,  74,  85 
great  superficial  petrosal,  86 
hypoglossal,  50,  51,  53,  75 
inferior  dental,  78 
branches  of,  80 
resection  of,  262 
infra-orbital,  33,  77,  78 

resection  of,  261 
lacrimal,  77 
lingual,  79,  263 
mandibular,  78 

auriculotemporal  branch,  79 

branches,  79 

inferior  dental  branch,  79 

internal  pterygoid  branch,  79 

lingual  branch,  79 

recurrent  branch,  79 
maxillary,  branches,  77 

course,  77 

infra-orbital  branch,  78 

malar  branch,  78 

meningeal  branch,  77 

orbital  branch,  77 

sphenopalatine,  branches,  78 

superior  dental  branch,  78 

temporal  branch,  77,  78 

temporomalar  branch,  77 
mental,  79,  80 

resection  of,  261 
mylohyoid,  80 
nasal,  zz,  77 
nasopalatine,  34,  81 
oculomotor,  74 
olfactory,  74 
optic,  2,2,,  74 
phrenic,  49 

pneumogastric,  49,  5°,  63,  74,  i4S 
posterior  auricular,  85 

palatine,  34,  81 


INDEX 


283 


Nerve,  seventh  cervicofacial  divi- 
sion, 85 
short  ciliary,  80 
sixth,  33 

small  superficial  petrosal,  86 
spinal  accessory,  50,  75 
st}-loglossal,  85 
stylohyoid,  85 

superficial  cervical,  47,  58 

superior  dental,  77 
third,  2>i 

to  stapedius  muscle,  85 
trifacial,  74,  75 

deep  origin,  75 

divisions,  76 

function,  75 

Gasserian  ganglion,  76 

mandibular  division,  78 

maxillary  division,  77 

motor  root,  76 

ophthalmic  division,  76 

superficial  origin,  75 

s>mpathetic  ganglia,  80 

union   of   motor   and   sensory 
roots,  78 
trochlear,  74 
vidian,  81,  86 
Neuralgic  and  fracture  of  mandible, 

245,  254 
minor,  256 
quinti  major,  256 
trifacial,  256 
Neuroma,  163 
New  growth,  162 
Nitrous  oxid,  132 
action  of,  143 
advantages  of,  141 
and  ether  anesthesia,  136 
and  oxygen,  141,  142 
anesthesia,  141 
cyancjsis,  142,  143 
indications  for,  141 


Nitrous    oxid    anesthesia,   method 
of  administration,  142 
preparation  for,  142 
stertorous  breathing  in,  143 
disadvantages,  141 
Noma,  186 
Nose,  floor  of,  36 
lateral  wall,  36 
meati  of,  36 
roof  of,  35 
septum,  36 
Novocain,  130 

and  adrenalin  chlorid,  131 


Occipital  bone,   basilar    process, 

29,  32 
condyloid  process,  29 
horizontal  portion,  32 
protuberance,  external,  29 
Oculomotor  nerve,  74 
Odontocele,  171 
Odontoma,  166,  170 
Olfactory  foramina,  32 

nerve,  74 
Operation,  preparation  of  field,  148 

of  mouth,  148 
Ophthalmic  artery,  33 
ganglion,  80 
nerve,  branches,  76 
vein,  33 
Opisthotonos,  223 
Optic  foramen,  32,  33 

nerve,  33,  74 
Oral  cavity,  94 
Orbicularis  oris,  59 
Orbit,  28,  32 

bones  forming,  32 
floor,  32 
inner  wall,  33 
openings  into,  33 
outer  wall,  33 
roof,  32 


284 


INDEX 


Orbital  plate  of  frontal  bone,  29,  42 

process  of  palate  bone,  38 
Os  linguae,  26 

planum,  20 
Osteoblasts,  114 
Osteochondroma,  163 
Osteoma,  163,  166,  167 
Osteomyelitis,  106,  192 

and  pyemia,  118 

cocain  and,  193 

dioxid  of  hydrogen  and,  192 

etiology,  192 

mercury  and,  193 

phosphorus  and,  193    • 

septicemia  and,  194 

symptoms,  194 

treatment,  195 
Osteoplastic  flap,  155 
Osteosarcoma,  163,  166,  168 
Osteotome,  150 

spiral,  154 
Ostium  frontale,  38,  43 

maxillare,  38,  41 
Otic  ganglion,  55,  82 
Otitis  media  and  facial  paralysis, 

264 
Ovale,  foramen,  29,  32 
Oxygen  in  ether  anesthesia,  140 

with  nitrous  oxid,  141 

Pain,  cause  of,  in  inflammation,  103 
Palatal  process  of  maxilla,  33 
Palate  bone,  36 

cell  in  orbital  process  of,  38 
horizontal  plate,  2,Z 

hard,  ZZ,  94 

soft,  94 
Palatine  fossa,  anterior,  21 
PapiUoma,  163,  166 
Papular  eruption  in  syphilis,  175 
Paralysis,  facial,  264 

musculospiral,  138 


Parotid  fascia,  48 
gland,  67,  88 

and  typhoid  fever,  205 
carcinoma  of,  166,  205 
inflammation,  166,  171,  205 
mixed  tumor  of,  205 
swelling  of,  and  ankylosis  of 
temporomandibular  joint, 
205 
and  facial  paralysis,  205 
teratoma  of,  205 
tumors  of,  205 
lymph-glands,  72 
lymph-node,  swelling  of,  205 
mixed  tumor  of,  166,  171 
space,  89 
Parotitis,  205 
Periostitis,  106 

Perpendicular  plate  of  ethmoid,  19 
Petechia,  109 
Petrous  portion  of  temporal  bone, 

29,  32 
Pharyngeal  plexus,  53 
Pharynx,  muscles  of,  53 

posterior  wall  of,  94 
Phlebitis,  118 
Phosphorus  and  osteomyeHtis,  193 

necrosis,  194 
Pillars  of  fauces,  92 
Plaster,  adhesive,  157 
Platysma  myoides,  47 
Plexus,  brachial,  51 

cervical,  50 

pharyngeal,  53 
Pneumococcus,  107 
Pneumogastric  nerve,  74 
Poikilocytosis,  98 
Pol3TDi  of  maxillary  sinus,  203 
Potassium  iodid  in  syphilis,  182 
Premaxillary  bone,  34,  233 
Prevertebral  fascia,  48 
Probe,  150 


INDEX 


285 


Process  of  widening  dental  arch,  34 
Processus  gracilis  of  malleus,  45 
Prognathism,  inferior,  239 
Pterj-goid  fossa,  29 

process,  19,  29,  36 
PtyaUn, 88 

Pulse  in  ether  anesthesia,  134 
Pupil  in  ether  anesthesia,  134 
Pus,  102 

Pustular  eruption  in  syphilis,  I75 
Putrefaction,  115 
Pyemia,  cause  of,  118 

definition  of,  116 

prognosis  of,  119 

secondary  abscesses  in.  118 

symptoms,  118 

treatment,  119 

Quinsy,  212 

Ranula,  206 
calculus  and,  207 
etiology,  207 
seton  in,  207 
symptoms,  207 
treatment,  207 
varieties,  207 
Raphe  of  floor  of  the  mouth,  95 
Ray-fungus,  108,  197 
Reactions  of  degeneration,  267 
Reflex,  corneal,  138 
Repair  of  bone,  114 
of  tissue,  113 

by  first  intention,  114 
by  second  intention,  114 
by  third  intention,  114 
Resection  of  inferior  dental  nerve 
262 
of  infra-orbital  nerve,  261 
of  mental  nerve,  261 
Resolution,  loi 
Retractors,  150 


Rhagades,  178 
Rigor,  116 
Rivinus,  ducts  of,  9I 
Rodent  ulcer,  166 
Roof  of  mouth,  33 

syphilitic  necrosis  of,  i77 

of  nose,  34 
Root  cyst,  171 
Roseola  in  syphilis,  17S 
Rostrum  of  sphenoid,  36 
Rotundum,  foramen,  32 
Rubber  dam  for  drainage,  112,  157 

tubing,  156 
Rupia,  176 


Salivary  fistula,  207,  263 
treatment,  208 
glands,  adenoma,  166 
diseases  of,  205 
Salivation,  181 
Salvarsan,  181 

powder  in  Vincent's  angina,  188 
Sapremia,  causes,  116 
definition,  115 
differential  diagnosis,  116 
prognosis,  116 
symptoms,  116 
treatment,  116 
Sarcoma,  163,  165,  166,  168 
diagnosis,  from  carcinoma,  165 
giant-celled,  165 
small  round-celled,  165 
spindle-celled,  165 
Scalpel,  149 

Scarpa,  foramen  of,  21,  34 
Scissors,  149 
Sella  turcica,  32 
Septicemia,  bacteria  in,  117 
definition  of,  115 
prognosis,  117 
symptoms,  117 
treatment,  117 


286 


INDEX 


Septum  of  nose,  36 

Sequestrum,  194 

Serum  diagnosis  of  syphilis,  179 

treatment  in  hemorrhage,   125, 
128 
Seton,  207 

Shock,  Crile's  method  of  treatment, 
122 

definition,  120 

pathology  of,  1 20 

symptoms,  121 

treatment  of,  121 
Sigmoid  notch,  23 
Silk,  155 

Silkworm  gut,  155 
Silver  wire,  155 
Sinus,  cavernous,  65 

frontal,  37,  42 

maxillary,  37,  39 

pathologic,  102 

sphenoid,  38,  43 
Skin,  sterilization  of,  148 
Skull,  anterior  region  of,  28 

as  a  whole,  28 

base  of,  29 

bones  of,  18 

general  development,  17 

lateral  aspect,  28 
Socia  parotidis,  89 
Soft  palate,  muscles  of,  53 
Spasm  of  glottis,  138 
Sphenoid  body,  32,  36 

bone,  18 
anterior  clinoid  process,  29 
greater  wing,  18,  29 
hamular  process,  12) 
lesser  wing,  19,  29 
pterygoid  process,  19,  29,  36 

fissure,  32,  33 

greater  wing,  32 

middle  clinoid  process,  32 

rostrum  of,  36 


Sphenoid  sinus,  38,  43 

outlet,  43 
Sphenomaxillary  fissure,  t,2) 

fossa,  41 
Sphenopalatine  ganglion,  81 
Spinal  accessory  nerve,  75 
Spinosum,  foramen,  29,  32 
Spiral  osteotome,  154 
Spirochaeta  pallida,  108,  174,  179 
Splints,  112 
Squamous  suture,  29 
Square  knot,  155 

of  neck,  surgical,  48 
Staphylococci,  106 
Stasis,  100 

Stenson,  duct  of,  89,  263 
obstruction  of,  206 

foramen  of,  21,  34 
Sterilization,  iodin  in,  148 

of  skin,  148 
Stoma ta,  loi 
Stomatitis,  183 

aphthous,  183 

arsenical,  189 

catarrhal,  183 

gangrenous,  184,  187 

mercurial,  188 
symptoms,  188 
treatment,  189 

simple,  183 

toxic,  188 

ulcerative,  184 
Stovain,  130 
Streptococcus  and  cellulitis,  106 

pyogenes,  106 
in  pyemia,  118 
Strep  to  thrix  bo  vis,  197 
Strep  to  trichosis,  197 

etiology,  197 

prognosis,  198 

symptoms,  197 

treatment,  198 


INDEX 


287 


Styloid  process,  29 
Stylomastoid  foramen,  29 
Styptic,  physiologic,  128 
Sublingual  fossa,  23 

gland,  91 
Subluxation  of  temporomandibular 

joint,  239 
Submaxillary  fossa,  23 

ganglion,  82 

gland,  50,  85 

inflammation  of,  206 
tumors  of,  206 

lymph-glands  and  carcinoma,  214 
inflammation  of,  213 
Sulphur  granules,  198 
Suppuration,  loi,  102 
Supramaxillary    branch    of    facial 

nerve,  86 
Supra-orbital  foramen,  28 
Surgical  engine,  152,  262 

fever,  115 
aseptic,  115 
septic,  115 
varieties,  115 

line  of  common  carotid  artery,  63 
Suture,  155 

catgut,  155 

continuous.  155 

coronoid,  29 

horsehair,  155 

intermaxillary,  opening  of,  34 

interrupted,  155,  156 

lambdoid,  29 

method  of  tying,  156 

silk,  155 

silkworm  gut,  155 

silver  wire,  155 

squamous.  29 
Swelling,  cause  of,  in  inflammation, 

103 
.Sympathetic  ganglia,  80 
Syncope,  120 


Syncope,  treatment,  121 
Synovial  sacs,  46 
SyphiHd,  tubercular,  175 
Syphilis,  174 

adenopathy  in,  175 

and  cleft  palate,  231 

and  leukoplakia,  173 

cause  of,  108 

chancre,  174 

diagnosis  of,  newer  methods,  1 79 

etiology,  168,  174 

gumma,  176,  177,  179 

hereditary,  178 

Hutchinson's  teeth,  178 

"606" in, 181 

in  the  mouth,  176 

incubation  period,  1 74 

intermediate  period,  176 

macular  eruption,  175 

mercurial  salivation  in,  181 

mercury  in,  181 

mucous  patches  in,  175,  177 

necrosis,  177,  179 

papular  eruption  in,  175 

potassium  iodid  in,  182 

primary  stage,  1 74 

pustular  eruption  in,  175 

rhagades,  178 

roseola,  175 

rupia,  176 

salvarsan  in,  181 

secondarj^  stage,  1 75 

skin  eruption,  1 75 

sore  throat  in,  1 75 

spirochaeta  pallida,  1 74 

stages  of,  1 74 

tertiary  stage,  1 76 

treatment  of,  180 
in  late  cases,  182 
of  mouth  in,  181 

treponema  i)a!lidum  as  cause,  179 

ulcers  in,  175 


288 


INDEX 


Syphilis,  Wassermann  reaction,  1 79 
Syphilitic    ulcer,    diagnosis    from 
tuberculous  ulcer,  178 

Tannic  acid,  125 
Taste,  sense  of,  85 
Teeth   and   diseases   of   maxillary 
sinus,  201 
and  fractures  of  mandible,  245 
and  trifacial  neuralgia,  257 
blood  supply  of,  68,  70 
course  of  blood  to  and  from,  70 
deciduous,  extraction  of,  229 
extraction  and  local  anesthesia, 

131  -    - 

Hutchinson's,  178 
impacted,  224 
lower,  nerve  supply,  80 
upper,  nerve  supply,  78 
veins  from,  70 
Temporal  bone,  glenoid  fossa,  42 
petrous  portion,  29,  32 
squamous  portion,  32 
tympanic  plate,  45 
muscle,  55 
Temporomandibular     articulation, 
42 
Joint,  42 

ankylosis  of,  217 
dislocation  of,  215 

interarticular  fibrocartilage, 
46 
ligaments  of,  45 
luxation  of,  215 
subluxation  of,  239 
synovial  sacs,  46 
Teratoma,  163 
Tetanus,  112 

and  ankylosis,  223 
bacillus,  107 
Thermocautery,  171 
Thrush,  187 


Thyrohyoid  membrane,  27 
Thyroid  cartilage,  63  • 

Tic  douloureux,  256 

nerves  involved  in,  258 
Tissue,  granulation,  114 

repair  of,  113 
Tongue,  51 

carcinoma  of,  166 

depressor,  152 

dorsum  of,  95 

extrinsic  muscles,  51 

gumma  of,  177 

muscles  of,  51 

nerve  supply,  79 

relation  to  roof  of  mouth,  93 
Tonsillar  crypts,  secretion  of,  213 

space,  92 
Tonsillitis,  follicular,  212 

suppurative,  212 
Tonsils,  92,  95 

blood  supply,  94 

diphtheric  infection  of,  212 

diseases  of,  211 

effects  of  hypertrophy  of,  211 

faucial,  94 

functions,  94 

hypertrophy  of,  211 
treatment  of,  211 

lingual,  94 

pharyngeal,  94 

relations  of,  92 

structure,  94 
Tooth  extraction  and  ether  anes- 
thesia, 135 
hemorrhage  following",  125 
Tracheotomy,  144 
Transfusion,  126 
Transillumination,  201 
Trephining,  152 

Treponema  pallidum,  108,  174,  179 
Triangle,  inferior  carotid,  49 

occipital,  50 


INDEX 


289 


Triangle  of  neck,  48 
anterior,  48 
posterior,  49 
subclavian,  50 
submaxillary,  50,  90 
superior  carotid,  49 
Triangular  cartilage,  36 
Trifacial  ner\'e,  74,  75 

ophthalmic  di\dsion,  33 
neuralgia,  256 

alcohol  injection,  263 

anesthesia  and,  257 

central  lesions  and,  256 

classification,  256 

diagnosis,  259 

etiology,  256 

general  diseases  and,  257 

paUiative  treatment,  260 

peripheral  causes  of,  257 

prognosis,  259 

removal  of  Gasserian  ganglion, 

263 
resection  for,  260 
symptoms,  257 
teeth  and,  257 
treatment  of,  259 
a;-ray  in,  259 
Trismus  of  tetanus,  223 
Trochlear  nerve,  74 
Tube,  Eustachian,  54,  55 
Tubercle  bacillus,  107 
Tubercular  syphilis,  175 
Tuberculous  ulcer,  diagnosis  from 

syphilitic  ulcer,  178 
Tumors,  162 

adcnofibroma,  163 
adenoma,  163,  166 
angiofibroma,  163,  166,  169 
associated  with  face  and  jaws, 

166 
benign,  164 

carcinoma,  163,  164,  166 
19 


Tumors,  clinical  classification,  164 
chondroma,  163,  166 
classification  of,  163,  166 
Cohnheim's  theory,  162 
connective-tissue  type,  163,  166 
cystic,  164 

epithelial  type,  163,  166 
epithelioma,  163,  166 
epulis,  168 
etiology  of,  162 
fibroma,  163,  166 
fibromyoma,  163 
giant-cell  myeloma,  169 
intermediate  type,  164 
lipoma,  163,  166 
lymphangioma,  163 
lymphoma,  163 
malignant,  164 
metastasis  of,  164 
microbic  theory,  162 
mixed,  of  parotid  gland,  205 

type,  163,  166 
myeloma,  163 
myelosarcoma,  163,  166 
myoma,  163 
neuroma,  163 
odontocele,  171 
odontoma,  166,  170 
of  maxillary  sinus,  203 
of  parotid,  mixed,  166,  171 
osteochondroma,  163 
osteoma,  163,  166,  167 
osteosarcoma,  163,  166,  168 
pajjilloma,  163,  166 
root  cyst,  171 
sarcoma,  163,  166,  168 
teratoma,  163 
Turbinated  bone,  inferior,  36 

middle,  37 

superior,  38 
processes  of  ethmoid,  36 
Tympanic  plate,  29,  45 


290 


INDEX 


Typhoid  bacillus,  107 
fever,  parotid  gland  in,  205 

Ulcer,  inflammatory,  104 

of  cornea,  263 

rodent,  166 

syphilitic,  175 

traumatic,  105 

trophic,  105 
Ulceration,  104 
Unciform  process,  38 
Uvula,  54,  55,  95 

Vein,  anterior  external  jugular,  47 

external  jugular,  69 

facial,  50 

inferior  thyroid,  49 

internal  jugular,  49,  50,  63,  69, 
70,  14s 

lingual,  50 

middle  thyroid,  49 

of  head,  69 

ophthalmic,  33 

posterior  external  jugular,  47 

ranine,  50 ' 

subclavian,  51 

superior  thyroid,  50 
Vertical  plate  of  ethmoid,  19,  36 
Vessels,  anterior  ethmoid,  zi 
palatine,  34 

infra-orbital,  33 

posterior  ethmoid,  33 
palatine,  34 
Vestibule  of  mouth,  95 
Vidian  nerve,  81 
Vincent's  angina,  188 
Vomer,  36 

alae  of,  36 
Vomiting  during  anesthesia,  139 

treatment  of,  117 


Wassermann  reaction,  179 
Wharton,  duct  of,  90 
Whitehead's  varnish,  112 
Willis,  circle  of,  69,  71 
Wound  and  tetanus,  112 
cleansing  of,  in 
contused,  no 
definition,  no 
drainage  of,  in 
dressing  of,  in 
gunshot,  no 
incised,  no 
infected,  no 
lacerated,  no 
of  face,  15s 
of  mouth,  113 
of  mucous  membranes,  113 

cleansing  of,  113 

closure  of,  113 

drainage  of,  113 

hemorrhage  of,  113 

infection  of,  113 

made  by  surgeon,  113 

suture  of,  113 

tincture  of  iodin  in,  113 

treatment,  113 
penetrating,  no 
punctured,  no 
suture  of,  in 
symptoms,  no 
treatment  of,  in 

X-'&AX  and  ankylosis,  221 
and  empyema  of  maxillary  sinus, 

201 
and  impacted  teeth,  228 
and  necrosis,  195 
in  fracture  of  mandible,  248 
in  trifacial  neuralgia,  259 

Zygoma,  28,  29 


SAUNDERS*   BOOKS 


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Dercum's  Mental  Diseases 

Mental  Diseases.  A  Clinical  Manual.  By  Francis  X. 
Dercum,  M.  D.,  Ph.  D.,  Professor  of  Nervous  and  Mental  Dis- 
eases  at  Jefferson  Medical    College,    Philadelphia.     Octavo  of 

479  pages.       Cloth,   $3.50  net.     Second  Edition  published  November,  1917 

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that  tells  you  how  to  diagnose,  how  to  treat — either  at  home  or  in  an  in- 
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Church  and  Peterson's 
Nervous  arid  Mental  Diseases 


Nervous  and  Mental  Diseases.  By  Archibald  Church, 
M.D.,  Professor  of  Nervous  and  Mental  Diseases  and  Head  of 
Neurologic  Department,  Northwestern  University  Medical  School, 
Chicago;  and  Frederick  Peterson,  M.  D.,  formerly  Professor 
of  Psychiatry  in  Columbia  University,  New  York.  Octavo  of  940 
pages,  with  350  illustrations.     Cloth,  $5.00  net. 

Published  October,  1914 

EIGHTH  EDITION 

For  this  new  eighth  edition  the  entire  work  has  been  most  thoroughly- 
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American  Journal  of  the  Medical  Sciences 

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IS  two  books.  .  .  .  The  descriptions  of  disease  are  clear,  directions  as  to  treatment  definite, 
(ud  disputed  matters  and  theones  are  omitted.     Altogether  it  is  a  most  useful  text-book." 


Herrick's  Neurology 

Introduction  to  Neurology.      By  C  Judson   Herrick, 

Ph.  D.,  Professor  of  Neurology  in  the  University  of  Chicago. 

i2mo  of  360  pages,  illustrated.     Cloth,  $1.75  net. 

A  KEY  TO  NEUROLOGY 

Professor  Herrick's  new  work  will  aid  the  student  to  organize  his  knowl- 
edge and  appreciate  the  significance  of  the  nervous  system  as  a  mechanism 
right  at  the  beginning  of  his  study.  It  is  sufficiently  elementary  to  be  used 
by  students  of  elementary  psychology  in  colleges  and  normal  schools,  by 
students  of  general  zoology  and  comparative  anatomy  in  college  classes,  and 
by  medical  students  as  a  guide  and  key  to  the  interpretation  of  the  larger 
works  on  neurology.  Published  September,  1915 


XERVOrS   AXD   MEXTAL   DISEASES 


Kaplan's  Serology  of  Nervous 
and  Mental  Diseases 

Serology  of  Nervous  and  Mental  Diseases.     By  D.  M. 

Kaplan,  M.  D.,  Director  of  Clinical  and  Research  Laboratories, 

Neurological  Institute,   New  York  City.     Octavo  of  346  pages, 

illustrated.  PubUshed  June,  1914.  Cloth,  $3.50  net. 

ILLUSTRATED 

This  is  an  entirely  new  work  on  tliis  subject.  Here  you  get  the  newest 
technic — the  application  of  serology  in  practice.  You  get  the  indications, 
contra-indications,  preparation  of  patients,  technic,  after-phenomena,  after- 
care, and  disposal  of  the  fluids  obtained  by  lumbar  puncture.  You  get  the 
physical,  chemical  and  cytologic  properties  of  normal  and  pathologic  fluids 
discussed  in  detail,  including  the  interpretation  of  findings  and  bacteriology. 
You  get  a  full  discussion  of  the  serology  of  all  nervous  and  mental  diseases 
of  non-luetic  etiology — meningeal  affections  (infectious  and  non-infectious), 
brain  diseases,  cord  diseases,  nerve  affections  (including  disorders  of 
inttrnal  secretion),  the  psychoses,  and  the  intoxications.  The  serology  of 
every  type  of  luetic  nervous  and  mental  disease  is  next  presented  to  you, 
giving  the  IVassermann  reaction  in  detail^  the  use  of  salvarsan  and  neo- 
salvarsan. 


Elsberg's  Surgery  of  Spinal  Cord 

Surgery  of  the  Spinal  Cord.  By  Charles  A.  Elsberg, 
M.  D.,  Professor  of  Clinical  Surgery,  New  York  University  and 
Bellevue  Hospital  Medical  School.  Octavo  of  330  pages,  with 
153  illustrations.      Cloth,  $5.00  net. 

ORIGINAL  ILLUSTRATIONS 

(Published  July.  1916) 

There  is  no  other  Ijouk  publislied  like  this  by  Dr.  Elsberg.  It  gives  you  in 
clear  definite  language  the  diagnosis  and  treatment  of  all  surgical  diseases  ol 
the  spinal  cord  and  its  meml)r.ines,  illustrating  each  operation  with  original 
pictures.  Because  it  goes  so  thoroughly  into  symptomatology,  diagnosis,  and 
indications  for  operation  this  work  appears  as  strongly  to  the  general  practitioner 
and  neurologist  as  to  the  surgeon.  'Jhe  first  part  of  the  work  is  devoted  to  anatomy 
and  physiology  of  the  spinal  cord,  and  to  the  symptomatology  of  surgical  spinal 
'iiseases.  The  second  part  takes  up  operations  upon  the  spine,  the  cord,  and 
nerve-roots.  The  third  part  is  given  over  to  surgical  diseases  of  the  cord  and 
Its  membranes — their  diagnosis  and  treatment.  Included  also  are  chapters  on 
hematomyelia  and  spinal  gliosis,  because  in  these  diseases  much  harm  is  done 
10  the  fiber  tracts  by  compression.  There  is  also  a  chapter  on  x-rays  in  spina) 
diseases. 


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Abt*s  Preparation  of  Infants'  Foods 

A  Practical  Guide  for  the  Preparation  of  Infants'  and  Chil- 
dren's Foods.  By  Isaac  A.  Abt,  M.  D.,  Professor  of  Diseases  of 
Children,  Northwestern  University  Medical  School.  i2mo  of  143  pages. 
Cloth,  ^1.25  net.  PubUshed  July,  1917 

In  this  book  Dr.  Abt  gives  to  young  mothers,  nurses,  and  those  who  care  for  infants 
and  children  minute  directions  on  the  preparation  of  every  kind  of  food  that  has  value 
in  infant  feeding.  Included  also  is  such  practical  materia!  as  diet-lists  for  constipa- 
tion, an  outline  of  a  plan  for  feeding  babies,  care  of  nipples  and  bottles,  etc.  You  are 
given  weights  and  measures;  the  mineral  constituents  and  caloric  values  of  foods;  and 
a  wealth  ot  recipes  for  foods  of  all  kinds  and  purposes. 


Hill  and  Gerstley's  Infant  Feeding 

Clinical  Lectures  on  Infant  Feeding.  By  Lewis  Webb  Hill, 
M.  D.,  Alumni  Assistant  in  Pediatrics,  Harvard  .Medical  School;  and 
Jesse  R.  Gerstley,  M.  D.,  Instructor  in  Pediatrics,  Northwestern 
University  Medical  School.  i2mo  of  377  pages,  illustrated.  Cloth, 
$2.75  net.  Published  October,  1917, 

In  these  clinics  you  are  given  the  full  details  of  the  Boston  methed  of  infant  feeding 
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clinical  examples.  The  book  is  equivalent  to  a  postgraduate  course  in  infant  feeding. 
It  brings  these  two  systems  right  to  your  door. 


Herrick  and  Crosby's  Laboratory  Neurology 

Labor.atory  Outlines  of  Neurology.  By  C.  Judson  Herrick, 
Ph.  D.,  and  Elizabeth  Crosby,  Ph.  D.,  of  the  Anatomical  Labor- 
atory of  the  University  of  Chicago.     i2mo  of  120  pages,  illustrated. 

Published  January,  1918 

Hecker,  Trumpp,  and  Abt  on  Children 

Atl.as  and  Epitome  of  Diseases  of  Children.  By  Dr.  R. 
Heckeh  and  Dr.  J.  Trumpp,  of  ISIunich.  Edited,  with  additions,  by 
Isaac  A,  Abt,  M.  D.  With  48  colored  plates,  144  text-cuts,  and  453 
pages  of  text.     Cloth,  $5.00  net.  Published  April,  1907 


CHI L D  R  E  N 


Ruhrah's  Diseases  of  Children 

A  Manual  of  Diseases  of  Children.  By  John  Ruhrah, 
M.  D.,  Professor  of  Diseases  of  Children,  College  of  Physicians 
and  Surgeons,  Baltimore.      i2moof552  pages,  fully  illustrated. 

Cloth,  $2.72  net.  Published  September,  1914 

FOURTH   EDITION 

The  fourth  edition  makes  this  work  more  than  ever  the  ideal  desk  book 
for  the  general  practitioner.  Although  there  have  been  added  over  one 
hundred  pages  of  new  matter  and  some  sixty  new  illu>trations,  the  book 
remains  of  a  handy  size  and  is  still  flexible. 

American  Journal  of  the  Medical  Sciences 

"Treatment  has  been  satisfactorily  covered,  being  quite  in  accord  with  the  best  teach- 
ing, yet  withal  broadly  general  and  free  from  stock  prescriptions." 


Griffith's  Care  of  the  Baby 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.  D., 
Professor  of  Pediatrics  at  the  University  of  Pennsylvania.  i2mo 
of  455  pages,  illustrated.     Cloth,  51.50  net.        PubUshed  June,  1915 

SIXTH  EDITION 
New  York  Medical  Journal 

"  We  are  confident  if  this  little  work  could  find  its  way  into  the  hands  of  every  trainee 
DUrse  and  of  every  mother,  infant  mortality  would  be  lessened  by  at  least  fifty  per  cent." 

Bandler's  The  Expectant  Mother 

Thi.s  is  decidedly  a  book  for  the  woman  preparing  for  child- 
birth. It  has  chapters  on  menstruation,  nourishment  of 
mother  during  pregnancy,  nausea,  care  of  breasts,  examination 
of  urine,  preparations  for  labor,  care  of  mother  and  child  after 
delivery,  twilight  sleep,  and  dozens  of  other  matters  of  great 
interest  to  the  expectant  mother.  Published  August,  1916 

t2nio  of  213  paj:es.  illustrated.     Hy  S.  Wyllis   Bandlf.r.  M    \)..  Profc-ssor  of  Diseases  of 
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Kerley's  New  Pediatrics 

Practice  of  Pediatrics.  By  Charles  Gilmore  Kerley,  M. 
D.,  Professor  of  Diseases  of  Children,  New  York  Polyclinic 
Medical  School  and  Hospital.     Octavo  of  913  pages,  illustrated. 

Published  January,  1918 

SECOND  EDITION 

This  is  an  entirely  new  work — not  a  revision  of  Dr.  Kerley's  earlier  work. 
It  is  not  a  cut-and- dried  treatise — but  the  practice  of  pediatrics,  giving,  of 
course,  fullest  attention  to  diagnosis  and  treatment.  The  chapters  on  the 
newborn  and  its  diseases,  the  feeding  and  the  growth  of  baby,  the  care  of 
the  mother's  breasts,  artificial  feeding,  milk  modification  and  sterilization,  diet 
for  older  children — form  a  monograph  of  125  pages.  Then  are  discussed  in 
detail  every  disease  of  childhood,  telling  just  what  measures  should  be  insti- 
tuted, what  drugs  given,  bo  valuable  prescriptions  being  included.  The 
chapter  on  vaccine  therapy  is  right  down  to  the  minute,  including  every  new 
method  of  proved  value — with  the  exact  technic.  There  is  an  excellent 
chapter  on  Gymnastic  Therapeutics,  giving  explicit  directions  for  the  correction 
of  certain  abnormalities  in  which  gymnastics  have  proved  efficacious. 
Another  feature  consists  of  the  16^  illustrative  cases — case  teaching  of  the 
most  practical  sort. 


Grulee's  Infant  Feeding^ 

Infant  Feeding.  By  Clifford  G.  Grulee,  M.  D., 
Assistant  Professor  of  Pediatrics  at  Rush  Medical  College. 
Octavo  of  326  pages,  illustrated,  including  8  in  colors.     Cloth, 

$3.2 1;  net.  Published  September,  1917 

THIRD  EDITION 

Dr.  Grulee  tells  you  how  to  feed  the  infant.  He  tells  you— and  shows  you  by 
clear  illustrations— the  techtiic  of  giving  the  child  the  breast.  Then  artificial 
feeding  is  thoughtfully  presented,  including  a  number  of  simple  formulas.  The 
colored  illustrations  showing  the  actual  shapes  and  appearances  of  stools  are 
extremely  valuable. 

Kerr*s  Diagnostics  cf  Diseases  cf  Children 

Diagnostics  of  the  Diseases  of  Children.  By  LeGrand  Kerr, 
M.  D.,  Professor  of  Diseases  of  Children,  Brooklyn  Postgraduate  Medical 
School,  Brooklyn.  Octavo  of  542  pages,  fully  illustrated.  Cloth,  ^5.00 
ngt_  Published  February,  1907 


HYGIENE 


Hoxie  and  Lapt&d's  Medicine  for  Nurses   Second  Edition 

Medicine  for  Nurses  and  Housemohhers.  By  George  Howard 
Home,  M.  D.,  Physician  to  the  German  Hospital,  Kansas  City;  and 
Pearl  L.  Laptad,  formerly  Principal  of  Training-School,  University  of 
Kansas.     i2rao  of  351  pages,  illustrated.     Cloth,  $1.50  net. 

Published  April,  1913 

The  purpose  of  this  book  is  to  provide  enough  information  about  the  nature,  cause 
and  cure  of  disease  to  enable  you  to  carry  out  the  doctor's  orders  intelligently,  to  know 
when  home  treatment  is  sufficient,  and  how  and  what  to  apply,  to  recognize  when  pro- 
fessional advice  should  be  sought,  and  how  to  render  first  aid  in  emergencies.  Jt  is 
just  the  manual  you  need  in  caring  for  illness  and  preventing  its  spread  in  your  home. 

Aikens'  Home  Nurse's  Hand- Book         New  (2d)  Edition 

Home  Nurse's  Hand-Book.  By  Charlotte  A.  Aikens.  i2mo 
of  303  pages,  illustrated.     Cloth,  $1.50  net  Published  March,  1917 

You  will  find  the  entire  realm  of  home  nursing  very  completely  presented  here.  The 
author  knows,  from  long  active  experience,  just  how  to  meet  emergencies,  how  to  im- 
provise, how  to  manage.  She  shows  you  what  to  have  ready  in  times  of  sickness,  how 
to  make  the  bed,  how  to  care  for,  feed,  and  bathe  the  patient,  how  to  give  home  treat- 
ments, and  what  they  are;  how  to  disinfect,  how  to  make  and  apply  bandages,  how  to 
render  first  aid  in  emergencies. 

"  Several  books  have  been  written  upon  home  nursing,  but  none  has  been  so  clear, 
so  simply  put,  so  easy  to  learn,  so  easy  to  teach,  so  free  from  matter  not  to  the  point, 
so  all-comprehensive." — Trained  Nurse  and  H',spital  Review. 

Galbraith's  Personal  Hy{(iene  and  Physical  Training 

for  Women  Second  Edition,  January.  1917 

Personal  Hygient;  and  Physical  Training  for  Women.  By 
Anna  M.  Galbraith,  M.D.,  Fellow  New  York  Academy  of  Medicine. 
i2mo  of  393  pages,  with  original  illustrations.     Cloth,  $2.25  net. 

This  is  a  book  for  every  woman.  It  tells  you  how  to  train  your  physical  powers  to 
their  fullest  development.  For  home  study  and  as  a  text-book  this  manual  has  no 
equal. 

"Just  the  information  that  every  woman  should  possess.  It  gives  more  valuable 
and  practical  help  than  we  have  ever  seen  in  any  other  one  volume." — Health  Culture. 

Galbredth's  Four  Epochs  of  Woman's  Life  Third  Edition 

The  Foi:r  Epochs  of  Wo.man's  Life.  By  Anna  M.  Galbraith, 
M.  D.  With  an  Introductory  Note  by  John  H.  Musser,  M.  D.  i2mo 
of  296  pages.      Cloth,  $1.50  net.  Published  March,  1917 

Women  have  at  last  awakened  to  a  sense  of  the  penalties  they  have  paid  for  their 
ignorance  of  those  laws  of  nature  which  govern  their  physical  being.  Maidenhood, 
marriage,  maternity,  and  menopause — these  are  the  periods  of  a  woman's  life  fraught 
with  the  greatest  dangers.  Well-ordered  education  in  these  subjects  lessens  suffering 
and  is  essential  to  prevention  of  disease.  Dr.  Galbraith  discusses  the  subject  in  a 
modest  and  conclusive  manner.  Sex  Instruction  is  handled  most  admirably.  There  is 
a  valuable  chapter  on  eugenics  and  a  glossary  of  medical  terms. 

"These  truths  should  l>e  known  by  every  woman,  and  I  gladly  commend  the  essay 
to  their  thoughtful  consideration  "—Z?c.  John  H.  Musser,  University  0/  Pennsylvania. 


SAUNDERS'    BOOKS    ON 


Winslow's  Prevention  of  Disease 

Prevention  of  Disease.  By  Kenelm  Winslow,  M.  D.,  formerly 
Assistant  Professor  of  Comparative  Therapeutics,  Harvard  University. 
i2mo  of  348  pages,  illustrated.     Cloth,  Si. 75  net.  November,  1916 

This  book  is  a  practical  guide  for  the  layman,  giving  him  briefly  the  means  to  avoid 
the  various  diseases  described.  The  chapters  on  diet,  exercise,  tea,  coffee,  and  alcohol 
are  of  special  interest,  as  is  that  on  the  prevention  of  cancer.  There  are  chapters  on 
the  prevention  of  malaria,  colds,  constipation,  obesity,  nervous  disorders,  tuberculosis, 
etc.     The  work  is  a  rec6rd  of  25  years'  active  practice. 

Brady's  Personal  Health 

Personal  Health,  A  Doctor  Book  for  Discriminating  People.  By 
William  Brady,  M.  D.,  Elmira,  N.Y.  i2mo  of  405  pages.  Cloth, ^1.50 
net.  Published  September,  1916 

Knowledge  is  the  only  protection  against  sickness'.  This  book  will  make  you  more 
efficient  in  preventing  illness  and  in  caring  for  those  who  are  ill  when  you  cannot  get 
a  doctor,  and  in  co-operating  with  him  when  you  can  get  one.  It  is  written  in  a  clear, 
concise,  and  simple  style.  It  is  wholly  understandable.  All  the  mystery  in  medicine 
is  swept  aside  and  you  are  told  what  is  most  worth  while  in  modern  medicine — your 
personal  health  and  how  to  maintain  it.  It  is  written  by  a  doctor  unusually  well 
qualified  to  present  medicine  to  the  lay  reader.     It  is  an  instructive  book,  indeed. 


Keefer's  Military  Hygiene 

Military  Hygiene  and  Sanitation.  By  Lieut. -Col.  Frank  R. 
Keeper,  Professor  of  Military  Hygiene,  United  States  Military  Academy, 
West  Point.      i2mo  of  305  pages,  illustrated.     Cloth,  ;jSi. 50  net. 

This  is  a  concise  though  complste  text-book  on  this  subject,  containing  chapters  on 
the  care  of  troops,  recruits  and  recruiting,  personal  hygiene,  physical  training,  pre- 
ventable diseases,  clothing,  equipment,  water  supply,  foods  and  their  preparation, 
hygiene  and  sanitation  of  posts  and  barracks,  the  troopship,  hygiene  and  sanitation  of 
marches,  camps  and  battlefields,  disposal  of  wastes,  tropical  and  arctic  service, 
venereal  diseases,  alcohol  and  other  narcotics,  and  a  glossary.  July,  1914 

Bergey's  Hygiene  Fifth  Edition 

The  Principles  of  Hygiene.  By  D.  H.  Bergey,  A.  M,,  M.  D., 
Assistant  Professor  of  Bacteriology,  University  of  Pennsylvania.  Octavo 
of  529  pages,  illustrated.     Cloth,  $3.00  net.         Published  September,  1914 

"  It  will  be  found  of  value  to  the  practitioner  of  medicine  and  the  practical  sanita- 
rian ;  and  students  of  architecture,  who  need  to  consider  problems  of  heating,  lighting, 
ventilation,  water  supply,  and  sewage  disposal,  may  consult  It  with  profit." 

Buffalo  Uledical  Journal. 


HYGIENE 


Owen's  Treatment  of  Emergencies 

The  Treatment  of  Emergencies.  By  Hibley  R.  Owex,  M.D., 
Surgeon  to  the  Philadelphia  General  Hospital.  i2mo  of  350  pages, 
with  249  illustrations.     Cloth,  $2.00  net.  Published  June,  1917 

Dr.  Owen's  book  is  a  complete  treatment  of  emergencies.  It  gives  you  not  only  the 
actual  tecknic  of  the  procedures,  but,  what  is  equally  important,  the  underlying  prin- 
ciples of  the  treatments,  and  the  reason  why  a  particular  method  is  advised.  This 
makes  for  correctness.  You  get  chapters  on  fractures  of  all  kinds,  going  fully  into 
symptoms,  treatments,  and  complications.  You  get  treatments  of  contusions,  of 
wounds,  both  lacerated  and  incised.  Particularly  strong  is  the  chapter  on  gun-shot 
wounds,  which  gives  the  new  treatments  that  the  great  European  War  has  developed. 
You  get  th-  principles  of  hemorrhage — arterial,  venous,  and  capillary— together  with 
its  constitutional  and  local  treatments.  You  get  chapters  on  sprains,  strains,  disloca- 
tions, burns  and  scalds,  treatment  of  sunburn,  chilblain,  asphy.xiation,  convulsions, 
hysteria,  apople.xy.  exhaustion,  opium  poisoning,  uremia,  and  electric  shock.  Y'ou  get 
sections  on  the  making  and  applying  of  bandages,  varieties,  and  precautions;  and  a 
complete  discussion  of  the  various  kinds  of  artificial  respiration,  including  mechanical 
devices.  You  are  told  what  equipment  is  necessary  for  emergency  work,  and  what 
household  remedies  should  be  always  on  hand. 

Morrow's  Immediate  Care  of  Injured        zS^ln 

Im.\iei)Iate  Care  of  the  Injured.  By  Albert  S.  Morrow,  M.  D., 
Major,  Medical  Reserve  Corps,  U.  S.  Army.  Octavo  of  356  pages, 
with  242  illustrations.     Cloth,  $2.75  net.  Published  November,  1917 

Pyle*s  Personal  Hygiene  The  New  (7th)  Edition 

A  Manuai.  of  Peksoxal  Hygiene:  Proper  Living  upon  a  Physio- 
logic Basis.  By  Eminent  Specialists.  Edited  by  Walter  L.  Pyle, 
.\.  M.,  M.  D.,  Assistant  Surgeon  to  Wills  Eye  Hospital,  Philadelphia. 
555  pages,  illustrated.     Cloth,  $1.75  net.  Published  August,  1917 

To  this  new  edition  there  have  been  added,  and  fully  illustrated,  chapters  on  Do- 
mestic Hygiene  and  Home  Gymnastics,   besides  an  Appendix  containing  methods  of 
Hydrotherapy,  Mechanotherapy,  and  First  Aid  Measures.     There  is  also  a  Glossary  of 
the  mechanical  terms  used. 
.  .:  :   "The  work  has  been  excellently  done,  there  is  no  undue  repetition,  and  the  writers 
..Jiave  succeeded  unusually  well  in  presenting  facts  of  practical  significance  based  on 
'  sound  knowledge." — Boston  Medical  and  Surgical  Journal. 

American  Pocket  Dictionary        New  ( loth)  Edition 

.\merican  Pocket  Medical  Dictionary.  Edited  by  W.  A.  New- 
man Dorland,  M:  D.  Containing  the  pronunciation  and  definition  of 
the  i)rincipal  words  used  in  medicine  and  kindred  sciences,  with  64  ex- 
tensive tables.  With  707  pages.  Flexible  leather,  with  gold  edges. 
Si. 25  net;  with  patent  thumb  index,  $1.50  net.  September,  1917 

Brill's  Psychanalysis  second  Edition 

I'svcuANALYSis;  Its  Theories  and  Practical  Application.  By  A.  A. 
Bkill,  Ph.  B.,  M.  IJ..  Clinical  Assistant  in  Neurology  at  Columbia 
University  Medical  School.    Octavo  of  392  pages.     Cloth,  $1.25  net. 

Published  May,  1914 


SAUNDERS'   BOOKS  ON 


Shaw  on  Nervous  Diseases  and  Insanity 

Fifth  Edition,  published  October.  1913 

Essentials  of  Nervous  Diseases  and  Insanity:  Their  Symptoms 
and  Treatment.  A  Manual  for  Students  and  Practitioners.  By  the 
late  John  C.  Shaw,  M.  D.,  Clinical  Professor  of  Diseases  of  the  Mind 
and  Nervous  System,  Long  Island  College  Hospital,  New  York.  i2mo 
of  204  pages,  illustrated.     Cloth,  $1.25  net.    Saunders'  Compends. 

Golebiewski  and  Bailey*s  Accident  Diseases 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.  By  Dr. 
Ed.  Golebiewski,  of  Berlin.  Edited,  with  additions,  by  Pearce  Bailey, 
M.  D.,  Consulting  Neurologist  to  St.  Luke's  Hospital,  New  York.  With 
71  colored  illustrations  on  40  plates,  143  text-illustrations,  and  549  pages 
Cloth,  $4.00  net.    Saunders'  Hand-Atlases.  Published  1901 

Bass  and  Johns'  Alveolodental  Pyorrhea 

Alveolodental  Pyorrhea.  By  Charles  C.  Bass,  M.  D.,  Pro- 
fessor of  Experimental  Medicine,  and  Foster  M.  Johns,  M.  D.,  Instructor 
in  the  Laboratories  of  Clinical  Medicine,  Tulane  Medical  College.  Octavo, 
168  pages,  illustrated.     Cloth,  $2.50  net.  Published  June,  1915 

Spear's  Nervous    Diseases 

A  Manual  of  Nervous  Diseases.  By  Irving  Spear,  M.  D.,  Pro- 
fessor of  Neurology  at  the  University  of  Maryland,  Baltimore.  lamo 
of  660  pages,  with  172  illustrations.    Cloth,  $2.75  net.     November,  1916 

Jakob  and  Fisher's  Nervous  System  Hand^iMM 

Atlas  and  Epitome  ok  the  Nervous  System  and  its  Diseases. 
By  Professor  Dr.  Chr.  Jakob,  of  Erlangen.  Edited,  with  additions, 
by  Edward  D.  Fisher,  M.  D.,  University  and  Bellevue  Hospital 
Medical  College,  New  York.  ^Vith  83  plates  and  copious  text.'  Cloth, 
#3.50  net.  Published  1901 

Hunt's  Diagnostic  Symptoms  of  Nervous  Diseases 

Diagnostic  Symptoms  of  Nervous  Diseases.  By  Edward  L. 
Hunt,  M.  D.,  formerly  Instructor  in  Neurology  and  Assistant  Chief 
of  Clinic,  College  of  Physicians  and  Surgeons,  New  York.  i3mo  of 
292  p^es,  illustrated.     Cloth,  I2.00  net.  Second  Edition,  June,  1917 


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